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Diabetes Coverage Change Safety Check

Clinical Continuity Tool

Diabetes Coverage Change Safety Check

A quick screen to reduce interruptions in insulin, medications, continuous glucose monitoring (CGM), pumps and supplies when insurance changes.

Created By

danatech Clinical Staff

Reviewed August 2026

Clinical Review

LG

Luriza Glynn, APRN, CDCES

EH

Erin Henry, FNP, BC-ADM

Use this check when A patient expects new coverage, receives a denial, changes jobs or plans, moves between Medicaid, Marketplace or Medicare, or says cost is affecting use.
Enrollment timing As of 2025, a low income on its own no longer lets someone enroll in Marketplace coverage year-round. Outside the annual open enrollment window, a person generally needs a qualifying life event — losing coverage, a move, marriage or a birth — to enroll. Flag timing early and route enrollment questions to a navigator or assister. Rules current as of August 2026. Confirm current windows and exceptions through the linked resources below.
Checklist progress0%
1

Ask three questions

This is an early-warning screen. If any answer below is No or Unsure (or if coverage is changing), work through Steps 2 through 4.

Coverage

Do you expect your health coverage or pharmacy benefit to change in the next couple of months?

Access

Have you confirmed that your current diabetes treatments and suppliers will remain covered?

Supply

Do you have enough medication and supplies to avoid a gap while coverage is changing?

One or more answers suggest a possible gap. Work through Steps 2 through 4 to protect continuity.
2

Verify what the new plan actually covers

High-cost and frequently restricted therapies may be subject to formulary changes, prior authorization, quantity limits and/or step therapy. Confirm updated requirements for patients taking these medications.

3

Protect continuity before the change

Clinician

Patient / care partner

4

Escalate urgent risks

Act today

If the patient could miss insulin doses, contact the prescriber or diabetes team the same day. A gap in insulin can lead to dangerously high glucose and diabetic ketoacidosis (DKA) within hours to days.

Point the patient to same-day help: free and lower-cost insulin, back-up supplies and patient assistance programs, through the danatech Affordability Program Finder, or call 211 for local insulin and supply support.

Act this week

If the patient is running low on pump or CGM supplies or another essential item, including expired or soon-to-expire glucagon, start replacement now. Use urgent prior authorization, exception, appeal, transition-fill, manufacturer assistance or community-resource pathways as available.

Refer for enrollment or eligibility help

When coverage, subsidy or eligibility questions exceed the clinical scope, route the patient to enrollment support early. With affordability shifting this year, this is often the highest-value referral you can make.

Marketplace assister or navigator Medicare SHIP counselor Medicaid agency or eligibility assister In-office or local social worker / social services Health-system financial navigator Plan member services
Linked chips open a national resource. Social services, financial navigator and plan member services are specific to your practice, health system or the patient’s plan.

Next step

danatech Affordability Program Finder

Search by product, brand or insurance type for cost-saving options like discounts, coupons and patient assistance programs.

Open the finder →
Practice pearls for prescribers Coverage and billing detail — tap to open
A pharmacy “not covered” message may not mean not covered at all. The item may be covered under a different benefit. This is especially common with CGMs and insulin pump supplies. Before concluding an item is not covered, check both the pharmacy and durable medical equipment (DME) benefits and confirm whether a specific supplier is required.
For insulin used in a pump, the Part B/Part D split follows durable versus disposable. For insulin used in a durable (non-disposable) pump covered under Part B, indicate “Process under Medicare Part B” or “Insulin for durable insulin pump.” For insulin that is injected, used in a pen, or used in a disposable patch pump (for example OmniPod or V-Go), indicate “Process under Medicare Part D.” The dividing line is durable versus disposable, not pump versus injection — a disposable patch pump is billed under Part D. See the CMS billing guidance.
Medicare CGM coverage requires a documented visit on a set schedule. A treating practitioner must have an in-person or Medicare-approved telehealth visit with the patient within the 6 months before ordering the CGM, and again every 6 months for continued coverage. Check current criteria and documentation requirements to help prevent delays or denials.
Patient handout (PDF)

Scope: This tool supports clinical continuity and informed questions. It does not determine eligibility, guarantee coverage or replace official plan documents. Benefits and requirements vary by plan and may change. Confirm directly with the health plan. Entries stay on this page only and are not saved when you close it.

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DISCLAIMERS: 

This site and its services do not constitute the practice of medical advice, diagnosis or treatment. Always talk to your diabetes care and education specialist or health care provider for diagnosis and treatment, including your specific medical needs. If you have or suspect that you have a medical problem or condition, please contact a qualified health care professional immediately. To find a diabetes care and education specialist near you, visit the ADCES finder tool.

ADCES and danatech curate product specifics and periodically review them for accuracy and relevance. As a result, the information may or may not be the most recent. We recommend visiting the manufacturer's website for the latest details if you have any questions.

danatech is made possible thanks to a generous grant from Helmsley Charitable Trust. Additional funding provided by: