Medicare covers Dexcom continuous glucose monitors, but the coverage rules depend on which Medicare plan you have and whether you meet specific medical requirements.

If you have Original Medicare (Part B), you can get coverage for a Dexcom system if your doctor prescribes it and you have type 1 or type 2 diabetes that requires insulin. Medicare Part B covers the monitor itself, the transmitter, and the sensors — the small patch you wear on your skin that reads your blood sugar. You typically pay 20 percent of the approved amount after you meet your Part B deductible, and the supplier must be enrolled with Medicare.

If you have a Medicare Advantage plan (Part C), coverage varies by plan. Some plans cover Dexcom the same way Original Medicare does; others may cover it differently or require you to use a specific supplier. You need to check your plan's formulary or call the plan directly to find out what your out-of-pocket cost will be.

Key Takeaways

  • Original Medicare Part B covers Dexcom systems for people with type 1 or type 2 diabetes who use insulin, after you meet your deductible.
  • Your doctor must write a prescription, and you must use a Medicare-enrolled supplier to get coverage.
  • Medicare Advantage plans have their own coverage rules, so you need to contact your specific plan to learn what you will pay.
  • You may need to try finger-stick testing or another glucose monitor first before Medicare will cover Dexcom, depending on your plan's requirements.
  • Sensors, transmitters, and the receiver are all covered under the same benefit — you do not pay separately for each piece.

How Original Medicare Part B Covers Dexcom

Original Medicare Part B treats Dexcom as durable medical equipment (DME). Once you meet your annual Part B deductible, Medicare pays 80 percent of the approved amount, and you pay 20 percent. The approved amount is set by Medicare, not by Dexcom's retail price, so your actual cost depends on what Medicare decides that amount is.

You need a prescription from your doctor stating that you have diabetes and use insulin. The prescription must come from a doctor who is enrolled with Medicare — most are, but it is worth confirming. You then order through a Medicare-enrolled DME supplier. That supplier handles the paperwork with Medicare and bills your insurance directly. You pay your 20 percent share to the supplier.

Sensors typically last 10 days, so you will need a new one every 10 days. Medicare covers the cost of sensors as part of the same benefit, so you do not face a separate deductible or coinsurance for each sensor. However, you will need to reorder through your supplier regularly.

Medicare Advantage Plans and Dexcom Coverage

Medicare Advantage plans (also called Part C) are run by private insurance companies that contract with Medicare. Each plan sets its own coverage rules for Dexcom. Some plans cover it identically to Original Medicare; others may require prior authorization from the plan before you start using it, or may have a higher copay or coinsurance.

The best way to find out what your plan covers is to call the customer service number on your insurance card and ask specifically about Dexcom coverage. Have your doctor's information ready, because the plan may ask whether your doctor is in-network or whether you meet the plan's medical requirements. Some plans require documentation that you have already tried other glucose monitoring methods first.

If your Medicare Advantage plan does not cover Dexcom or covers it only partially, you have the option to switch to Original Medicare during the annual open enrollment period (October 15 to December 7 each year). This can take time to arrange, so if you need Dexcom urgently, ask your plan about exceptions or appeals.

What You Need to Do to Get Coverage

Start by talking to your doctor. Tell them you want to use Dexcom and ask them to write a prescription. Your doctor will need to document that you have diabetes and use insulin — this is the medical requirement Medicare uses to decide whether to cover it.

Next, find a Medicare-enrolled DME supplier. You can search for suppliers on the Medicare website by entering your zip code, or ask your doctor's office for a recommendation. Many suppliers work with multiple insurance plans and handle the Medicare paperwork for you.

Contact the supplier and provide your Medicare information. The supplier will submit a claim to Medicare on your behalf. Medicare will review the prescription and your medical information to confirm you meet the requirements. This review typically takes one to two weeks. Once approved, the supplier will ship your Dexcom system and set up a schedule for sensor refills.

Prior Authorization and Medical Requirements

Some Medicare Advantage plans require prior authorization before you start using Dexcom. This means the plan wants to review your medical information and confirm you meet their specific rules before they agree to pay. Your doctor's office or the DME supplier can often submit this request on your behalf.

Medicare Part B does not always require prior authorization, but your specific situation may trigger a review. For example, if your prescription does not clearly state that you use insulin, Medicare may ask your doctor for more information before approving coverage.

A small number of plans require you to have tried finger-stick testing or another continuous glucose monitor first. This is called a "step therapy" requirement. If your plan has this rule, you may need to show records of using another method before the plan will cover Dexcom. Ask your plan directly whether this applies to you.

Out-of-Pocket Costs and Deductibles

With Original Medicare Part B, your out-of-pocket cost is 20 percent of the Medicare-approved amount after you meet your annual deductible. The deductible for 2024 is $240, but this amount changes each year. Once you meet the deductible, you pay 20 percent for all Part B services for the rest of the year.

If you have already met your Part B deductible for the year, you will pay 20 percent of the approved amount for Dexcom right away. If you have not met it, you will pay the full cost of your first sensor or system until the deductible is satisfied, then 20 percent after that.

Medicare Advantage plans have different cost structures. Some use copays (a flat dollar amount per sensor), others use coinsurance (a percentage), and some may have no cost after a deductible. Check your plan documents or call your plan to find out your exact cost.

Choosing a Medicare-Enrolled Supplier

Not every pharmacy or medical supply store is enrolled with Medicare as a DME supplier. You need to use an enrolled supplier for Medicare to cover the cost. Dexcom maintains a list of authorized suppliers on its website, and you can also search the Medicare supplier directory.

When you contact a supplier, ask whether they are enrolled with Medicare and whether they have experience processing Dexcom claims. A good supplier will handle the paperwork, follow up with Medicare if there are delays, and help you reorder sensors on schedule. Some suppliers offer automatic refill programs so you do not have to call every 10 days.

You can change suppliers if you are unhappy with the service. Just ask a new supplier to take over your account, and they will contact Medicare to transfer your prescription.

Frequently Asked Questions

Do I have to use insulin to get Medicare coverage for Dexcom?

Yes. Medicare Part B covers Dexcom only for people with diabetes who use insulin. If you manage your diabetes with oral medications alone, Original Medicare will not cover Dexcom. Some Medicare Advantage plans may have different rules, so check with your specific plan.

What if my doctor is not enrolled with Medicare?

Your doctor does not have to be enrolled with Medicare to write a prescription for Dexcom, but Medicare will only pay if the prescription comes from a doctor who is. Ask your doctor whether they are enrolled, or contact Medicare directly to verify. If your doctor is not enrolled, you may need to see another doctor who is to get a prescription that Medicare will accept.

How often do I need to reorder sensors, and does Medicare cover all of them?

Dexcom sensors last 10 days, so you need a new sensor every 10 days. Medicare covers the cost of all sensors you need as long as your prescription remains active and you continue to meet the medical requirements. There is no limit on the number of sensors Medicare will cover in a year.

Can I switch from Original Medicare to a Medicare Advantage plan if my plan does not cover Dexcom?

Yes, but only during the annual open enrollment period from October 15 to December 7. If you need Dexcom before then, ask your current plan about appeals or exceptions. Some plans will make exceptions for medically necessary equipment even if it is not normally covered.

What happens if Medicare denies my claim?

If Medicare denies coverage, your supplier or doctor's office will send you a notice explaining why. You have the right to appeal. Common reasons for denial include a missing or incomplete prescription, using a non-enrolled supplier, or not meeting the insulin requirement. Your supplier can often resubmit the claim with additional information to resolve the issue.