Does Medi-Cal Cover Dexcom G7? Eligibility, Costs, Denials

Yes, Medi-Cal covers the Dexcom G7 continuous glucose monitor. The device has been on the Medi-Cal Rx List of Contracted Continuous Glucose Monitoring Systems since October 2023, and eligible beneficiaries can get it through a pharmacy with prior authorization from their prescriber.1Medi-Cal Rx. Diabetic Supplies Updates – Dexcom G7 Most members pay nothing out of pocket.

Who Qualifies

Medi-Cal’s October 2023 coverage criteria approve a CGM for patients who fall into one of three groups:2Medi-Cal Rx. Medical Supplies – CGM Coverage Criteria and PA Bundling

  • Type 1 or type 2 diabetes with a documented history of regular insulin use over the past year.
  • Type 1 or type 2 diabetes with more than one level 2 hypoglycemic event (blood glucose below 54 mg/dL) in the past year despite treatment adjustments.
  • Gestational diabetes, for the duration of pregnancy plus 12 months after delivery.

An HbA1c result measured within the past eight months has to be on the authorization request. The prescriber can be an endocrinologist, primary care physician, nurse practitioner, physician assistant, certified nurse midwife, or another licensed provider experienced in diabetes management.2Medi-Cal Rx. Medical Supplies – CGM Coverage Criteria and PA Bundling

One boundary worth being clear about: a patient with type 2 diabetes who is not on insulin and has not had qualifying severe hypoglycemic events does not meet the criteria. Research on California’s Medicaid population has confirmed that non-insulin-using type 2 patients were excluded under the January 2022 expansion, and the 2023 rules keep insulin use or documented recurrent hypoglycemia as the gateway.3National Library of Medicine. CGM Coverage in California Medicaid

How to Get It

Since October 2022, CGMs have been pharmacy benefits under Medi-Cal Rx rather than durable medical equipment.4Medi-Cal Rx. Diabetic Supplies CGM Updates That means the path to a Dexcom G7 looks like a prescription, not a medical equipment order:

  1. Your provider writes a prescription for the Dexcom G7.
  2. Your provider submits a prior authorization request to Medi-Cal Rx using the DHCS 6560 form. Submission options include the CoverMyMeds portal, the Medi-Cal Rx Provider Portal, fax to 1-800-869-4325, or mail to Medi-Cal Rx Customer Service Center, Attn: PA Request, PO Box 730, Sacramento, CA 95741-0730.5San Francisco Health Plan. Medi-Cal Rx Provider FAQ
  3. Once approved, you pick up sensors at a participating pharmacy.

An approved authorization lasts one year. To renew, your provider documents that you still meet the original criteria and has had at least one annual visit confirming you are using the device and working toward HbA1c targets. That annual visit can be done by phone or video.2Medi-Cal Rx. Medical Supplies – CGM Coverage Criteria and PA Bundling6California Healthline. Medi-Cal Expands Patient Access to Diabetes Supplies

What You’ll Receive and Pay

The standard supply allowance is three sensors every 30 days (or up to nine in 90 days) and one receiver every three years.7Medi-Cal Rx. Reminder – Quantity Limit Restrictions for Common CGM Devices In June 2024, Medi-Cal Rx moved from fixed 30- and 90-day caps to a “quantity per day” framework, but prior authorization is still required if a claim goes above those limits.8Medi-Cal Rx. Updates to CGM and DIDDs Quantity Limits Each approved authorization lets you fill up to a 90-day supply at a time, so monthly pharmacy trips are not necessary. Medi-Cal beneficiaries generally pay nothing out of pocket for the device and sensors.6California Healthline. Medi-Cal Expands Patient Access to Diabetes Supplies

If You’re in a Managed Care Plan

Most Medi-Cal members are enrolled in a managed care plan rather than fee-for-service Medi-Cal, and CGMs are classified as a “partial carved-out medical supply.” That lets each managed care plan decide whether it provides the CGM benefit itself or routes it through Medi-Cal Rx.4Medi-Cal Rx. Diabetic Supplies CGM Updates Some plans, such as Molina Healthcare of California, moved their pharmacy benefits entirely to Medi-Cal Rx in January 2022, so their members follow the standard process above.9Molina Healthcare. Formulary Others handle CGM coverage internally with their own formulary and criteria. Call your plan’s member services line to confirm which path applies before your provider submits the request.

If Coverage Is Denied

You have the right to a state fair hearing through the California Department of Social Services, State Hearings Division. You can request one by phone at 1-800-743-8525 or 1-855-795-0634, by fax at 1-833-281-0905, or by mail to P.O. Box 944243, MS 21-37, Sacramento, CA 94244-2430.1Medi-Cal Rx. Diabetic Supplies Updates – Dexcom G7 For questions on CGM coverage or a pending authorization, the Medi-Cal Rx Customer Service Center is reachable at 1-800-977-2273.