Effective for dates of service on or after July 1, 2024, the South Carolina Department of Health and Human Services (SCDHHS) is expanding its existing coverage of continuous glucose monitoring (CGM) for full-benefit Healthy Connections Medicaid members. CGM will be covered under either the pharmacy or durable medical equipment (DME) State Plan benefit.

CGM will be covered with prior authorization (PA) that includes the following criteria.

1. CGM must be prescribed by one of the following qualified healthcare providers:
2. 1. primary care provider (a physician, physician assistant or advanced practice registered nurse);
   2. obstetrician; or
   3. endocrinologist
3. Eligible Medicaid members must have one of the following clinical criteria:
4. 1. Type 1 diabetes mellitus;
   2. Gestational diabetes; or
   3. Type 2 diabetes with one of the following:
   4. 1. Any type of insulin dependency or
      2. Non-insulin treated diabetes who have recurrent moderate (level 2) or have had at least one severe (level 3) hypoglycemic event

Submitting a PA

DME providers must file PA requests to SCDHHS’ Quality Improvement Organization (QIO). DME PA requests can be submitted:

• By phone at 1-855-326-5219;
• By fax at 1-855-300-0082; or
• By email at atrezzoissues@Kepro.com

Pharmacy providers must file PA requests to SCDHHS’ pharmacy benefit manager, MagellanRx Management. Pharmacy PA requests can be submitted:

• By phone at 866-247-1181;
• By fax at 888-603-7696

South Carolina’s Healthy Connections Medicaid managed care organizations (MCOs) are responsible for the authorizations, coverage and reimbursement related to the services described in this bulletin for Healthy Connections Medicaid members enrolled in an MCO.

Updated policy language will be available in the Physicians Services and Durable Medical Equipment Services provider manuals available on SCDHHS’ website by July 1, 2024.

Providers should direct any questions related to this bulletin to the Provider Service Center (PSC). PSC representatives can be reached at (888) 289-0709 from 7:30 a.m.-5 p.m. Monday-Thursday and 8:30 a.m.-5 p.m. Friday. Providers can also submit an online inquiry at: https://www.scdhhs.gov/providers/contact-provider-representative.

SCDHHS is expanding coverage for CGM devices under the Healthy Connections Medicaid program.Photo bySweet LifeonUnsplash