Dexcom G6 CGM coverage

Wednesday, Jul 21, 2021

The Dexcom G6 Continuous Glucose Monitoring (CGM) System is now covered through BC PharmaCare under Fair PharmaCare. The process for Pacific Blue Cross members to obtain coverage of the Dexcom G6 CGM is changing.

On June 11, 2021, the Government of British Columbia announced that the Dexcom G6 CGM is now covered through BC PharmaCare for eligible British Columbians.

BC PharmaCare will provide coverage to those who are 2 years old and up with diabetes mellitus and require multiple daily injections of insulin or insulin pump therapy as part of intensive insulin therapy. Full eligibility criteria can be found below.

Pacific Blue Cross supports this change, which will provide British Columbians living with diabetes more options for diabetes management. As such, we will be matching coverage criteria for the Dexcom G6 CGM for our Members. This is to ensure that the medical devices and medications covered by our plans are the right products at the right price to protect both the health of our Members as well as the sustainability of our plans.

Applying for coverage

All new and existing Pacific Blue Cross members must now apply for BC PharmaCare coverage of the Dexcom G6 CGM. Please follow the steps below to obtain BC PharmaCare coverage.

  1. Ensure that you are registered for Fair PharmaCare.
  2. Contact your primary care provider or diabetes specialist to initiate the Special Authority approval process and to request a prescription for the Dexcom G6 CGM.
  3. Once approved, bring your prescription to your local pharmacy. You can check the status of your approval by calling your prescriber or pharmacist to confirm, or by calling PharmaCare at 1-800-663-7100 (toll-free) or 604-683-7151 (from the Lower Mainland).
  4. Your pharmacist will be able to provide your Dexcom G6 CGM supplies and submit your claim to BC PharmaCare as well as issue you a receipt to submit to Pacific Blue Cross for reimbursement.
  5. If approved, your initial BC PharmaCare Special Authority approval period is valid for one year. After that, it may be renewed for five years. All Dexcom G6 CGM purchases covered by BC PharmaCare need to be made at your pharmacy. Dexcom will be phasing out its online store over the next several months.

Additional resources

For more information on BC PharmaCare coverage and the Special Authority and Fair PharmaCare programs please see the following links:

Register for Fair PharmaCare.

How to apply for Special Authority from BC PharmaCare.

BC PharmaCare diabetes supplies coverage and eligibility.

 

Frequently Asked Questions

  1. What is changing?

    The Dexcom G6 CGM is now covered through BC PharmaCare under Fair PharmaCare, Plan C (Income Assistance), Plan F (At Home Program), or Plan W (First Nations Health Benefit). Pacific Blue Cross members must now apply to PharmaCare for Dexcom G6 CGM coverage.

  2. Who is eligible for coverage?

    Check your member profile to see if the Dexcom G6 CGM is a benefit under your Pacific Blue Cross plan. If CGM devices are a benefit under your plan you can work with your prescriber to obtain coverage through BC PharmaCare.

    Individuals who meet the following criteria will be eligible for BC PharmaCare coverage:

    • Requires multiple daily injections of insulin or insulin pump therapy as part of intensive insulin therapy, AND
    • The patient/family/caregiver agrees to comprehensive and age-appropriate diabetes education by an interdisciplinary diabetes healthcare team and commits to regular follow-up, AND
    • The patient has one of the following:
      • Hypoglycemia unawareness, OR
      • Frequent and unpredictable hypoglycemic episodes, OR
      • Unpredictable swings in blood glucose, OR
      • At least one functional restriction that inhibits the use of blood glucose test strips (BGTS) (e.g., dexterity, mobility, dermatological problems), OR

    An occupation where hypoglycemia presents a significant safety risk (e.g., pilots, air traffic controllers, commercial drivers).

  3. How can I receive BC PharmaCare and Pacific Blue Cross coverage?

    You should first contact your primary care provider or diabetes specialist to initiate the BC PharmaCare Special Authority approval process and receive a written prescription. Your prescriber can complete the Special Authority Request. Once the Special Authority application has been submitted, approval may take 5-8 weeks. You should confirm that the request has been approved before bringing the prescription to their local pharmacy. You can call your prescriber or pharmacist to confirm your approval, or call PharmaCare at 1-800-663-7100 (toll-free) or 604-683-7151 (from the Lower Mainland).

    The PharmaCare Special Authority form will be the only one required to obtain coverage from Pacific Blue Cross. You will no longer need to complete the Pacific Blue Cross prior authorization form.

    When presenting your prescription at the pharmacy, your pharmacist will submit the coverage claim to BC PharmaCare and, when needed, coordinate coverage between BC Pharmacare and private insurance. BC PharmaCare will not retroactively reimburse patients for benefits purchased before approval of a Special Authority request. Please note you will need to be registered with Fair PharmaCare.

    Please submit your pharmacy receipt to Pacific Blue Cross for processing and payment.

  4. I live outside of BC. How do I apply for coverage of the Dexcom G6?

    Members residing outside of BC should have their Prescriber or Diabetes Specialist complete the Dexcom G6 CGM request form and return to us for review.

  5. Once approved, where do I purchase the Dexcom G6?

    Anyone with PharmaCare Special Authority must get their Dexcom G6 supplies from a pharmacy. Over the next several months the Dexcom G6 online store will be phased out.

  6. How long will I be covered for the Dexcom G6?

    Initially users will be covered for one year. After that time, coverage may be renewed for 5 years if users continue to require intensive insulin therapy and their health care professional recommends that they would benefit from continued CGM use. Pacific Blue Cross will align coverage duration with PharmaCare.

  7. Does this change apply to all CGM devices?

    This change applies only to the Dexcom G6 CGM. There is no change for any other CGM or Flash Glucose Monitor (Freestyle Libre or Libre 2) at this time.

  8. Does Pacific Blue Cross provide CGM coverage?

    Pacific Blue Cross members should first check to see if CGMs are a benefit under their plan. Take note of any annual dollar maximums, copays, or deductibles.

    Pacific Blue Cross will align with BC PharmaCare’s criteria for Dexcom G6 coverage. If a member receives coverage through BC PharmaCare, Pacific Blue Cross will coordinate that coverage. No changes will be made for coverage of other CGM devices.

  9. Will PBC be making any system enhancements to better support members?

    We are working to enhance our system functionality to improve our Member experience by allowing pharmacies to bill us directly. We expect this functionality to be ready by the end of 2021.

  10. What is Continuous Glucose Monitoring (CGM)?

    Continuous Glucose Monitoring (CGM) is a method to track glucose levels throughout the day and night. Unlike a blood glucose meter (BGM), which provides just a single glucose reading, CGM systems can provide real-time, dynamic glucose information up to every five minutes. People living with diabetes can gain valuable insight about their glucose levels, rate, and direction of change, allowing them to proactively manage their diabetes. Studies have shown that CGM systems may help reduce A1C levels and reduce hypoglycemia.

  11. How does CGM work?

    CGM users insert a tiny sensor wire just underneath the skin with an applicator. An adhesive patch holds the sensor in place so the sensor can measure glucose levels in the interstitial fluid. A small, reusable transmitter connects to the sensor and sends real-time readings wirelessly to a receiver, so users can view the information. With the Dexcom G6 System, your current glucose data can be shown on a compatible smart device using the Dexcom G6 App, or on an optional receiver.

  12. What’s the difference between the Dexcom G6 CGM and the Freestyle Libre 2 System?

    The Dexcom G6 devices offers a similar member experience to the FreeStyle Libre 2 system. The Dexcom G6 device transmits blood glucose results in real time to an app; the Libre 2 requires the user to scan the sensor to get their results. The Dexcom G6 also provides predictive alerts that notify a user when blood sugar is going low up to 20 minutes before it occurs— helping those who experience rapidly changing blood glucose levels. Freestyle Libre 2 offers customizable alarms for users. The Dexcom G6 is indicated for users aged 2 and older while the Libre 2 is indicated for ages 4 and older. Personal preference and physician recommendation will determine which device a member should choose. The Dexcom G6 costs approximately $3,600 annually and the Libre 2 Flash is approximately $2,600 annually. The Dexcom G6 is covered by BC PharmaCare. The Freestyle Libre 2 is not a BC PharmaCare benefit.