Posted Apr 28, 2026
Healthfirst members with Type 1 or Type 2 diabetes may qualify for a Continuous Glucose Monitoring (CGM) device if eligible. Available to Medicare, Essential Plan, and QHP members through an in-network DMEPOS provider, not a pharmacy.
A printable PDF is available here.
Healthfirst members diagnosed with diabetes, including Type 1, and Type 2 diabetes may qualify for a Continuous Glucose Monitoring (CGM) device if they meet the established eligibility criteria.
For eligible Healthfirst Medicare, Essential Plan, and Qualified Health Plan (QHP) members. These devices must be obtained through an in-network Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) provider, rather than a pharmacy.
The following FAQs provide an overview of the processes and requirements for obtaining CGMs for eligible Healthfirst Medicare and Commercial members, including those enrolled in CompleteCare, Senior Health Partners (if Medicare is with Healthfirst), Increased Benefit, 65+, Connection, Life Improvement, and Signature Medicare PPO/HMO, Essential, and Qualified Health Plans.
CGMs must be obtained through an in-network Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) provider, rather than a pharmacy. To request CGMs, follow the steps below.
1. Identify a preferred in-network supplier: The following three suppliers currently supply CGMs on behalf of Healthfirst.
2. Submit a prior authorization request: Submit your prior authorization requests to the preferred in-network DMEPOS supplier with the following documentation
Once the prior authorization request is approved, the supplier will deliver the item to the member directly.
CGM sensors are approved under a monthly allowance. 1 unit covers the member’s supply for the entire month (usually 2-4 sensors per month). The number of sensors dispensed is based on the frequency of sensor changes as per manufacturer’s instructions. If additional sensors are needed, the member should contact the DME provider who supplied their CGM.
If a member has a scheduled test, such as a CT scan and is due for a sensor change, they should wait until after the testing to apply the new sensor. All members should also have a backup blood glucose meter to use if they need to take the sensor off for CT scans or other imaging.
NYS Medicaid members enrolled in mainstream Managed Care Plans (MMC), or Personal Wellness Plan (PWP)/Health & Recovery (HARP) Plans receive pharmacy benefits through the NYRx Pharmacy Program. This program covers diabetic diagnostics, glucose testing supplies, and insulin syringes. Providers billing for these services must submit their claims directly to Medicaid Fee-For-Services (FFS) for reimbursement.
The member should go through their Medicare plan to obtain their CGM.
If you have any questions, please contact your Network Account Manager, or call Provider Services at 1-888-801-1660, Monday to Friday, 8:30am-5:30pm.
