Coverage for Dexcom CGM

ADP coverage for Dexcom G6 rtCGM is available for adults and children (2 years and older) living with type 1 diabetes, who are residents of Ontario and have a valid Ontario health card. Qualified individuals for the ADP funding will receive 100% coverage for their Dexcom G6.

To be eligible for coverage, individuals must meet the following Medical Eligibility Criteria:

1. Applicant has type 1 diabetes.
2. Applicant meets one of the following.
   • Owing to their developmental stage or a previously diagnosed cognitive or physical impairment, Applicant is
     • unable to recognize or communicate symptoms of hypoglycemia; or
     • independently perform fingerstick glucose testing.
   • Applicant had severe hypoglycemia in the past 2 years without an obvious precipitant, despite optimized use of insulin therapy and glucose monitoring (at least 4 times/day) which result in one of the following.
     • suspension of the applicant’s driving license
     • hospitalization or emergency room or EMS visit
     • glucagon administration, unconsciousness, or seizure
3. Applicant demonstrates experience with and commitment to managing blood sugar control and an ability to use rtCGM safely and effectively by all of the following.
   • commitment to long-term diabetes follow-up through regular assessments by diabetes educators, and prescribers at intervals deemed appropriate by the Diabetes Education Program;
   • agrees to full-time rtCGM wear;
   • agrees to share the data components of the Ambulatory Glucose Profile (AGP) with the diabetes health care providers/team such as:
     • precent time in target range, percent time above or below target range, precent time in hypoglycemia
     • visual representation of average 24-hour glucose profile for a 2-week period

For your patients living with type 1 diabetes that meet the medical eligibility criteria stated above, they will need to be assessed and followed by healthcare professionals associated with a Diabetes Education Program (DEP) registered with the ADP.

For your patients with private insurance, a prescription for Dexcom G6 should be provided with the notation "ADP Pending" written on it, to enable uninterrupted coverage on their private health plan pending ADP determination.

Current patients may be eligible to receive ADP coverage for the sensors and transmitters used with their current rtCGM system if they meet all of the following:

• use a rtCGM covered by the ADP;
• are under the supervision or care of an ADP-registered DEP; and,
• a physician or nurse practitioner, registered with the ADP-registered DEP as a prescriber, confirms that prior to starting real time continuous glucose monitoring, they met the device-specific Medical Eligibility Criteria.

If your patient meets the criteria listed above, an ADP Application Form may be submitted on their behalf. When completing the application, it may be necessary to answer ‘No’ to the questions in section 2a/2b. In such circumstances, it is recommended to complete a rtCGM Funding Exception Request Form (click to view sample) and submit it along with the ADP Application Form.

If you are not affiliated with a DEP registered with the ADP, you will need to refer individuals who meet the ADP medical eligibility criteria to an ADP registered clinic. Patients can also self-refer to a DEP registered with the ADP of their choice.

At the assessment appointment, a member of the DEP will confirm the patients’ eligibility and help them complete the rtCGM application form which will need to be sent to Dexcom. Dexcom will submit the completed form to ADP on your patients’ behalf.

For a list of DEP clinics registered with the ADP: https://www.ontario.ca/page/insulin-pumps-and-diabetes-supplies#section-3

The estimated wait time between referral and an assessment appointment may take from 30 to 60 days.

Patients can expect their ADP assessment to take approximately 2-3 weeks after the submission of their application form. ADP will notify Dexcom of the patient’s application status:

• If approved, Dexcom will notify the patient to update them on their successful application and confirm the details of their first order. Dexcom G6 supplies will be delivered at no cost to your patient.
• If rejected, Dexcom will notify the patient of their unsuccessful application and discuss their options moving forward. ADP will also notify the patient and prescribing healthcare provider at the DEP to provide the reason for denial.

Once the patient has been approved, Dexcom will contact the patient to confirm their status and deliver Dexcom G6 supplies directly at no cost. Dexcom will also provide one (1) Dexcom G6 Receiver at no cost to each approved patient who does not have a compatible smart device.

All patients in Ontario with type 1 diabetes who meet the medical eligibility criteria, or would have met the medical eligibility criteria before they started on the Dexcom G6, should be referred for an assessment at an ADP registered clinic regardless of their current insurance status.

Individual private insurance plans may differ and are subject to change. At this time, it is anticipated that private insurers already covering Dexcom G6 will expect plan members with type 1 diabetes to be assessed for ADP funding. To help ensure uninterrupted coverage for these patients on their private health plan pending ADP determination, provide them with a prescription for Dexcom G6 with the notation "ADP Pending" written on it, in conjunction with their referral to ADP.

The initial approval duration is two years. To continue receiving ADP coverage, patients must meet the Renewal Eligibility Criteria and complete the Renewal Form to confirm their continued eligibility every two years.

Following the ADP assessment, the completed application form should be submitted to Dexcom as soon as possible by secure fax at 1-844-348-0784 or by encrypted email at [email protected].

Click here to download a PDF summary of the Ontario ADP coverage information.

Click here to download a printable PDF copy of the ADP Application for Funding Real-Time Continuous Glucose Monitoring System (rtCGM).