“On Jan. 1, 2027, Dexcom is off-formulary on my Aetna health plan, and Abbott Freestyle Libre is on. I’m OK with it, except about a brand new CGM Prior Authorization ¶ mandate Caremark is implementing. Non-medical switches on medical devices and medicines are all about rebate kickbacks to the insurance company-owned PBM, not cost containment. Catch my blog post at Scott's Web Log: Dexcom Is Out. Libre Is In. I'm Happy, Except About the Prior Authorization (PA).”
A new prior authorization for a CGM, from the parent company bragging that it’s cutting them.
Come January, people on at least one plan from Aetna, a CVS Health Company will need a prior authorization for their CGM that they never needed before, from a company that says it’s cutting them. Scott Strumello, a longtime advocate in the diabetes community, shared this news on his blog…His plan is dropping Dexcom and making FreeStyle Libre the preferred CGM, with the same quantity limits and a brand-new prior authorization on top.
In June 2025, health insurers publicly pledged to fix prior authorization. CVS Health, which owns both Aetna and CVS Caremark, keeps saying it is reducing them. Then it adds one to a device people with diabetes depend on every hour of every day. And the formulary isn’t any more open: one brand is in, the other is out. WHY?
Now look at what that means for the patient.
Get your endo’s office to file the PA before January 1, or risk a gap in sensors.
Learn a new sensor and a new app.
If your insulin pump talks to your Dexcom, figure out what happens to your automated insulin delivery.
Call the pharmacy, call the plan, call again.
People with diabetes already carry more paperwork than ever, and for the young adults we serve at The Link, often on their first employer plan, it’s one more thing to learn the hard way.
If your plan is changing CGM coverage for 2027, check now whether a prior authorization is required and give your endo’s office an early heads-up. Then tell me in the comments what your plan sent you.
In case you are affected by this, And some of the time it depends on what plan you have from an employer etc.
An appeal from your doctor can work in many cases. Before Medicare when they removed Humalog from the formulary I was able to get it approved, but at a higher cost, tier 3.
With Medicare, this year my plan through a past employer chose CVS Silverscripts and it dropped Omnipod Dash, Humalog and Afrezza from the formulary, my doctor appealed it and it was approved. Again though it is at tier 3 in cost. It went pretty easy, next year who knows. They could decide to make the appeal process more laborious and difficult and not work. They are really pushing generic drugs and you choosing an alternative generic instead of a brand name drug. In my case the above items had no alternative and the letter I got turning my scripts down even stated that. That could be why it was approved on appeals so fast.
I get Dexcom through DME through Medicare, so this new change shouldn’t affect me. Dexcom charges way to much for their sensors and since Medicare has started bargaining with companies (can’t blame them) I could see them cutting a better deal with Abbot. Especially since Dexcom has proven many times over they are perfectly capable at putting sensors out at a cheaper price. For years they have charged UK customers a much cheaper price for the exact same sensor and now they have come out with an even cheaper version there and here. You can’t calibrate the new cheaper versions, but it is supposed to be pretty much the same thing. Calibration is important to me as mine are oftentime off by 30-40 points.
This is where a good and helpful endo can be critical for our scripts.
This only affects people on (US) Medicare who use Part C, and maybe not then. On original Medicare CGMs and blood test strips are paid for by Part B. In my case I had to go to a mail order supplier (the local pharmacies wouldn’t fill the prescription).
For Omnipod on Medicare the coverage depends on Part C vs Original too. Insulet’s list is here:
but that may be incomplete and it is for Omnipod 5 (I use Dash). O5 supports both Dexcom and Abbott so the swap shouldn’t be a problem but other commercial AID systems may not.
@jbowler I am on Medicare now, so CGM supplies are through Part B and won’t be affected by the change mentioned above and completely covered.
Re: Omnipods The classification for Omnipods before Medicare were the Omnipods were DME. But now under Medicare it’s Part D Formulary/Medicare, and through my husbands past employer switched to a Silverscripts plan through CVS instead of Optum. They are trying to trim costs and are really pushing people to go on generic drugs. Omnipods are uniquely classified under Part D and were dropped from the current formulary, however on appeal it has been approved and filled. I am not on Part C. I am Part A, Part B and Part D with a gap policy. The Part D and the gap is through my husbands past employer. I believe there is always an appeal process when you are turned down for what is deemed as a necessity, but it doesn’t always get approved.
To make it worse for Omnipod it isn’t enough to use Medicare.gov because even today the Omnipod does not appear on the formulary. If you do get the opportunity to swap a Part D, as I have, Insulet are are really good resource because they will go through the Part D policies that are available and get the coverage information. I did that last year.
If you have a good Part D and it is paid for by someone else stick with it; the appeal process should always work because changing to a tubed pump is obviously a major medical decision.
This year the Part D prices are going through the roof. All my available plans have a deductible of $700 (the maximum permitted) or a premium which is more than $1200 higher than the high-deductible options. The OOPMax has gone up from $2100 to $2400.
Price-wise Part C plans seem to be even worse. Ignoring the one MA-only plan that is available where I live most of them have a $0 premium with a $7150-$7900 OOPMax. The MA-PD plans with a non-zero premium sometimes have a lower OOPMax but in my experience the premium plays the plan for all or most of the difference (this was certainly true with ACA plans.)
EDIT: the above OOPMax ($7150-$7900) does not include the prescription drug max, which is apparently the same as Original Part D ($2400). The $0 premiums therefore have an OOPMax of $9,550-$10,300. I hadn’t realised that before.
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