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Senate committee holds DHS rule to route CGM coverage through pharmacies after DME providers warn of access and cost risks
Summary
The Senate Public Health Committee deferred a DHS rule to expand continuous glucose monitor coverage through pharmacy point-of-sale billing (WAC pricing) after DME providers warned the shift could raise prices, undermine DME home-delivery and case management, and concentrate market power with manufacturers; the committee voted to hold the rule for further review.
The Senate Public Health, Welfare and Labor Committee voted to hold a contested Department of Human Services rule that would expand continuous glucose monitor (CGM) coverage under Medicaid to be payable through pharmacy point-of-sale billing using wholesale acquisition cost (WAC) pricing and a $10.50 dispensing fee.
DHS said the rule implements Act 393 (2023) and was approved by CMS. The change would let pharmacies provide CGMs as a pharmacy benefit, allow the Medicaid program to collect pharmacy rebates and require point-of-sale pharmacy billing rather than the current DME billing pathway. DHS staff told the committee the WAC methodology is needed so the program can identify exactly what was…
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