Before long, people using the Dexcom continuous glucose monitor (CGM) may be able to walk into a local pharmacy and buy a box of sensors for a small co-pay or at least a lower cost than we're used to.
At least a half-dozen insurance plans -- including big carriers Anthem and United Healthcare (UHC) -- have started covering CGM supplies as a pharmacy benefit as of July 1, and Dexcom says more will be coming soon.
This doesn't necessarily mean sensors are available at your own local CVS or Walgreens just yet, but it is a first step to making that a reality and it is already an option for some Dexcom customers.
The move to make CGM sensors a pharmacy benefit has been a big initiative for Dexcom in 2015, one we heard a lot about during the diabetes advocacy MasterLab event in July. The company's leadership also touted this during their summer investor earnings call, saying they hope to see more pharmacies carrying their product as we move into 2016.
CGM Supplies as a "Pharmacy Benefit"
Covering the sensors as a "pharmacy benefit" essentially means they'll be billed through the prescription or pharmacy part of your health plan instead of as a "medical benefit" under the category "Durable Medical Equipment (DME)," which is how many diabetes devices are now handled.
If something is considered DME (like insulin pumps), you generally can only get it through the manufacturer itself or a third-party supplier like Edgepark. But if it's considered a pharmacy benefit, you generally have the option to purchase the item in a retail pharmacy, or by mail-order -- a huge convenience to customers.
So how much will you be paying? Well, since Your Insurance May Vary, as they say, the price tag is totally dependent on your
coverage. Your plan may require only a low, fixed co-pay applied to all pharmacy benefit items. But other plans require co-insurance, where you pay a percentage of the actual cost of the item, while yet other plans may require that you meet an annual deductible before any
co-pay or co-insurance kicks in.
So far, some big plans including Anthem, UHC, Affinity and Healthfirst have signed on to cover Dexcom CGM sensors as a pharmacy benefit, as well as some union and smaller plans in the Pacific Northwest, Southern California, the South and Midwest or Mid-Atlantic and Rocky Mountain regions.
Note for Anthem and related insurers: this doesn't mean that ALL Blue Cross Blue Shield (BCBS) or state Blue Shield plans are on board, and sadly I fall into the not-on-board category as I'm told by my plan that CGM sensors are not currently a covered pharmacy benefit. So I for one still need to go through Dexcom or a third-party supplier and pay my higher insurance deductible to get my supplies.
But we've heard from many in the Diabetes Community (through Facebook and Twitter responses) that their CGM sensors are now covered through distributors as a pharmacy benefit. One D-Mom tells us she gets them for $0 now (!), instead of having to pay the 20% co-insurance cost as when the sensors were previously considered DME. Others have told us they're getting sensors directly from a local CVS or through mail-order pharmacy suppliers, at a reduced co-pay of around $60 or $70 for a box.
As Dexcom develops next-gen tech, chances are we'll see more of this pharmacy coverage.
Dexcom's newly approved G5 mobile is just now beginning to ship, and down the road the longer wear G6 planned for 2017 will likely be even more affordable and appealing if available by pharmacy for a lower cost.
Same, too, as the Dexcom-Google agreement to develop an even more consumer-friendly mini-CGM materializes over the next few years, and we're expecting to see more and more big pharmacy chains with CGM tech on their shelves. (We're thinking Target stores!)
Mail Order and Retail
Dexcom's goal is to process about 70% of its CGM business through mail order and retail pharmacies over the next several years, according to the company's VP of Strategy and Corporate Development Steve Pacelli. He says Dexcom probably won't stock retail pharmacies like CVS or Walgreens anytime soon, but rather would "drop ship" to fill orders for pickup 24 hours later.
Presumably, that "just in time" shipping policy is meant to avoid pharmacies stockpiling expired sensors that they can't sell, or running out of supply.
We asked Medtronic, the other CGM provider, whether they plan to push for retail pharmacy sales as well, but they sidestepped the question. MedT acknowledges that pharmacy channel is something they're open to helping patients pursue if it's available, but they are not actively advocating for this kind of retail distribution. Paraphrasing their response: "It's not up to the manufacturer or patient, but the (private) insurance company to make that happen." Well, Duh. But see how Dexcom's working this, and showing that a CGM vendor can push for these changes, if it wants to.
CGM Access with Medicare
Of course, while this an exciting development in the world of CGM coverage, the bigger issue remains that CGM is not covered at all and therefore not affordable for people on Medicare. That remains an important topic of advocacy in our D-Community, which continues pushing for Congress to consider legislation that would mandate the Centers for Medicare and Medicaid Services (CMS) create a coverage category for CGM.
This is actually an area where Medtronic is indeed actively advocating. Some of us in the DOC were part of a conference call on Wednesday hosted by the company, in their role as part of a coalition of industry, academic, non-profit and patient advocacy groups working to garner support on this CGM Coverage legislation. Dexcom's included in that group too, of course.
Medtronic says they're ramping up Capitol Hill advocacy in October and hoping for action on this CGM access legislation before year's end. Particularly important is to make sure the Senate Finance and House Ways & Means committees are targeted -- especially the influential Republican lawmakers on those committees and those who also serve in the Congressional Diabetes Caucus (whose mission is to educate lawmakers on diabetes issues and support legislative activities that would improve diabetes research, education and treatment).
So while access to CGM under Medicare remains a battle, it's exciting to see Dexcom making it more practical for many PWDs to get their needed CGM supplies so easily, right at their local pharmacies.
I personally am looking forward to the day when I can walk into Walgreens or CVS and buy my CGM sensors there, instead of having to wrangle with the manufacturer on the phone, pay a higher premium, and wait for them to be delivered. And I sure hope that once I hit Medicare age, I can still affordably use a CGM.