What you need to know

Effective July 1, 2026, Prime revised the step therapy requirement within the Continuous Glucose Monitor (CGM) utilization management (UM) policy. This change is designed to ensure we are fully aligned with the latest diabetes clinical practice guidelines, which now support the use of CGMs for every type of diabetes.  

With this update, the step therapy requirement expands from insulin use only to include a history of any diabetes medication. This creates a less restrictive coverage pathway and broadens access to CGMs while remaining aligned with current medical standards. 

For awareness only; no action is required.  

Overview
 
The change applies to members who are newly seeking CGM coverage. Current members receiving CGM therapy will not be impacted due to continuation-of-therapy provisions within the policy. 

Note: There are no changes to CGM product tiering, formulary coverage or provider workflows. While the updated criteria may result in increased utilization because more members are expected to qualify for coverage, the policy continues to support appropriate clinical use of CGMs. We revised the UM policy to align with clinical practice updates. 

Questions
Reach out to your Prime account team representative.