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2025 Medicare Diabetes Prescribing Aid

Date: 05/21/25

2025 Diabetes Prescribing Aid

MAPD: HMO, HMO C-SNP, HMO D-SNP, PPO

Real-Time Prescription Benefit Tool

Gives providers visibility to a member’s coverage details via the EHR system.

  •  Member  ’s out of pocket cost
  •  Up to 3 medication options within a therapeutic class
  •  Up to 3 in-network pharmacy options

To learn more, visit: Evernorth Real-Time Prescription Benefit

2025 Preferred CGMs, Blood Glucose Meters and Strips

Continuous Glucose Monitoring (CGM) Systems:

  •  FreeStyle Libre or DexCom are preferred–PA required
  •  PA criteria (ALL 1–4):
  • 1. DM diagnosis.
  • 2. Insulin-treated, OR has problematic hypoglycemia documented by ONE (a. OR b.) of the following:
    • a.  More than one level 2 hypoglycemic event (BG <54 mg/dL) that persists despite more than one attempt to adjust medications and/or modify diabetes treatment plan. or
    • b.  One level 3 hypoglycemic event (BG <54 mg/dL) characterized by altered mental and/or physical state requiring third-party assistance for treatment.
  • 3. Seen by provider in last 6 months.
  • 4.  Will have follow-up appointments every 6 months to document adherenceto both the CGM regimen and diabetes treatment plan. The Coverage Determination form for PA request is available on our website.

 Subject to evidence of coverage 

  • Tiers  3–5:  Deductibles will apply 
  • Tier 6: Initial Co  verage $0–$10 monthly for C-SNP plans, $0 copay of all other plans 
  • D-SNP plans:   $0 copays across allphases of coverage
  • No co verage gap (donut hole) in 2025 
  • Max $35 monthly for insulin products

Blood Glucose Meters and Strips 

  • One Touch Verio Reflect or Verio Flex meter & One Touch Verio test strips, One Touch Ultra 2 meter & One Touch Ultra test strips 
  • Quantity Limits:
    •  1 meter kit per 365 days (1 per calendar year)
    •  100 test strips per 25 days (4 per day)
Drug ClassMedicationWellcare Dual Liberty, Dual Align (HMO D-SNP)Wellcare Specialty Simple (HMO C-SNP)Wellcare Simple (HMO), Wellcare Giveback (HMO), Wellcare Simple Value (HMO)Wellcare Simple Open (PPO)
Insulins Fast Acting: Insulin Aspart                                                                                    Tier 1 Tier 6Tier 3Tier 3
Insulins Short Acting: Novolin R U100   Tier 1 Tier 6Tier 3Tier 3
Insulins Intermediate: Novolin N U-100, Humulin R U-500  Tier 1 Tier 6: Novolin N               Tier 3: Humulin R  Tier 3
U-500		Tier 3Tier 3
Insulins Long Acting: Insulin Degludec U-100 AND U-200, Insulin Glargine YFGN U-100, Insulin Glargine U-300 Tier 1 Tier 3Tier 3Tier 3
Insulins Combinations: Novolin 70/30, Insulin Aspart Protamine-Insulin  Tier 1 Aspart Mix 70/30  Tier 1 Tier 6Tier 3Tier 3
Insulins Other Insulin Combinations: Xultophy, SoliquaTier 1 Tier 6Tier 3Tier 3
OralsBiguanide: Metformin,  Metformin ER (generic for Glucophage XR onlyTier 1 Tier 1 Tier 6Tier 6
Orals2nd Generation Sulfonylurea: Glipizide,Glipizide XR, GlimepirideTier 1 Tier 1 Tier 6Tier 6
OralsThiazolidinedione: PioglitazoneTier 1 Tier 1 Tier 6Tier 6
OralsAlpha-Glucosidase inhibitor: AcarboseTier 1 Tier 1 Tier 6Tier 6
OralsMeglitinide analogue: Nateglinide, RepaglinideTier 1 Tier 1 Tier 6Tier 6
OralsCombinations: Glipizide/ Metformin, Pioglitazone/Metformin, Pioglitazone/GlimepirideTier 1 Tier 1 Tier 6Tier 6
DPP-4  InhibitorsJanuvia, Tradjenta, SaxagliptanTier 1 Tier 6: Januvia, Tradjenta
Saxagliptan NOT PREFERRED		Tier 3Tier 3
Combinations with DPP-4 Inhibitors Glyxambi, Trijardy, Janumet, Janumet XR, Jentadueto,  Jentadueto XRTier 1 Tier 3: Glyxambi, Trijardy
Tier 6: Janumet,  Janumet XR, Jentadueto, Jentadueto XR		Tier 3Tier 3
SGTL2  InhibitorsFarxiga, Jardiance, InvokanaTier 1: Farxiga, Jardiance                                                             Invokana NOT PREFERREDTier 3: Farxiga, Jardiance
Tier 4: Invokana		Tier 3: Farxiga, Jardiance      Tier 4: InvokanaTier 3: Farxiga, Jardiance
Tier 4: Invokana
Combinations with SGTLS InhibitorsXigduo, Glyxambi, Synjardy, Synjardy XR, TrijardyTier 1 Tier 3: Xigduo, Glyxambi, Synjardy, Synjardy XR, Trijardy                                  Tier 4: Invokamet, Invokamet XRTier 3: Xigduo, Glyxambi, Synjardy, Synjardy XR, Trijardy                                        Tier 4: Invokamet, Invokamet XRTier 3: Xigduo, Glyxambi, Synjardy, Synjardy XR, Trijardy                                    Tier 4: Invokamet, Invokamet XR
GLP-1  AgonistsBydureon, Rybelsus, Trulicity, Ozempic, MounjaroTier 1 Tier 3Tier 3Tier 3