Folks who process PA (prior auths)- need your advice
15 years ago I was diagnosed T2 diabetes, and was put on Metformin and Januvia. I did "ok" on them but not great. The worst part for me was the fingersticks, 8-10 or more times a day to test blood sugar. After a couple years I just gave up and let myself go.
This past Aug I had reason to have labs drawn and the Dr mentioned my A1C was high (over 9) and I needed to take care of myself. I mentioned I was loathe to do the fingersticks again and my new job doesn't even have any privacy for me to do that multiple times a day. My T1 diabetes buddy showed me his Dexcom G7 continuous glucose monitor, and I was astonished. He said he rarely has to stick his fingers.
The Dr gave me a prescription for Mounjaro (Fed BCBS covered it due to the high A1C labs) and I got a prescription for the CGM's, and between the two I feel so empowered. The CGM is a game changer for me. However I am brand new to a federal job and have Federal BCBS Basic, and they are denying the coverage of the CGM's. Here is the link to the PA guidelines-
https://info.caremark.com/content/dam/enterprise/caremark/microsites/dig/pdfs/pa-fep/fep-criteria/FEP_Criteria_DexcomG7.pdf
Question- under "Prior-Approval Requirements" on Pg 1, the part that says "Patients who have filled at least one cumulative ≥84 day supply of a single insulin, a glucagon-like peptide-1 (GLP-1) agonist injection indicated for the treatment of diabetes mellitus, or an insulin/GLP-1 combination injection OR have filled CGM/CGM supplies in the past 180 days are exempt from these Prior Authorization (PA) requirements up to the PA quantity limits"… does this mean I just need to wait until I've refilled the 3rd month of Mounjaro and then I should be exempt from the PA requirements? They initially denied the CGM's based on the criteria outlined in number 2- the Dr didn't make a case for medical necessity and I didn't fulfill the requirements such as providing 2 months of fingerstick logs etc.
I paid out of pocket for the first month of CGM's, do you think I just need to do that for a couple more months and get two more months of Mounjara done, giving me the > or = 84 days amount, and then retry?
submitted by /u/Salty_snowbanks
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