Freestyle Libre 2 Plus CGM System — Cigna
Diabetes
Initial criteria
- Approve for 1 year if the patient meets ONE of the following (A or B):
- A) Patient is using an insulin regimen; OR
- B) Patient is taking a medication for glycemic control other than insulin AND meets ONE of the following (i or ii):
- i. Initial Therapy: Approve if the patient meets ONE of the following (a or b):
- a) Patient had a level 2 hypoglycemia event in the past 6 months; OR
- b) Patient had a level 3 hypoglycemia event in the past 6 months; OR
- ii. Patient is currently receiving a continuous glucose monitoring system AND meets ONE of the following (a or b):
- a) Patient had a level 2 hypoglycemia event in the 6 months prior to initial continuous glucose monitoring system prescription; OR
- b) Patient had a level 3 hypoglycemia event in the 6 months prior to initial continuous glucose monitoring system prescription.
Approval duration
1 year