For patients living with diabetes, starting a new device like an insulin pump or continuous glucose monitor (CGM) can be a major step forward- one that promises greater control, fewer disruptions, and better long-term outcomes. But getting to that point isn’t always easy. What should be a smooth and encouraging start is often delayed or derailed by access hurdles that complicate the process for both patients and providers.
Many of these devices are still routed through the durable medical equipment (DME) channel and reimbursed under the medical benefit. In this model, providers must navigate plan-specific distributor networks, each with their own forms, requirements, and routing rules. Because most DME suppliers operate outside of standard EHR and pharmacy systems, automation is limited. Faxed forms, phone calls, and manual documentation are common, and prior authorizations often require digging through patient charts for the right clinical notes, slowing the process even further.
For manufacturers, this system presents another challenge: a lack of visibility. Orders flow through a fragmented network of third-party distributors, making it hard to know where a patient is in the process, or if they’ve stalled or abandoned therapy altogether. Without centralized tracking or real-time updates, opportunities to intervene are few, and scaling support is difficult.
That’s starting to change. A growing number of diabetes devices are moving to the pharmacy benefit- a shift that promises faster adjudication, better alignment with provider workflows, and simpler fulfillment through specialty or retail pharmacies. In an ideal scenario, a provider writes an electronic prescription during the patient visit; within hours, the system confirms coverage and kicks off prior authorization automatically, then the patient gets a text with a clear update: “We’ve received your prescription and are working on approval.” A day or two later, a pharmacy rep calls to coordinate shipping and walk through setup. By the end of the week, the device is at the patient’s door. No guesswork. No faxes. No follow-up calls. Just a clear, coordinated experience that makes it easier to start and stay on therapy.
That kind of seamless experience is possible, but only with the right patient services program behind it. The pharmacy benefit model introduces new dynamics: prior authorization requirements, plan-specific routing, and fewer built-in support systems than the DME channel. Without thoughtful design and proactive support, even a well-intended transition can lead to delays, confusion, and gaps in care.
Why This Shift Matters
At first glance, pharmacy benefit coverage may seem like a win. It can eliminate certain barriers associated with DME, such as the need to identify covered distributors or manage third-party logistics. Retail or specialty pharmacies offer broader access, faster fulfillment, and less paperwork. Patients and providers familiar with the ease of filling a prescription may expect a similar experience here.
However, diabetes devices, whether continuous glucose monitors (CGMs), insulin pumps, or both, aren’t like traditional medications. They require personalized setup, training, and ongoing support. And they also come with a critical need to manage related supplies and, in many cases, coordinate insulin prescriptions. Unlike other products that have long been covered under the pharmacy benefit, newly transitioned devices and their associated components may introduce unfamiliar steps, payer-specific routing requirements, or new limitations on who can prescribe or dispense.
That’s where patient services programs play a critical role.
What Patients Need Now
Transitioning to the pharmacy benefit doesn’t mean patients need less support. It means the support must be smarter, faster, and better integrated. Effective patient services in this evolving environment should focus on three key areas:
Preserving the Best of the DME Experience
While the DME model has its challenges, it often delivers a high-touch experience that makes patients feel supported. As devices move to the pharmacy benefit, patient services must preserve the best of what worked before, clear navigation, personal outreach, and continuity of care, while layering in the speed and convenience expected from a retail experience.
That means building solutions that can:
Above all, it means delivering services that adapt to the needs of real people, those living with a chronic condition that already asks a lot of them.
Rising to the Occasion
The shift to pharmacy benefit coverage marks a turning point in diabetes care. It has the potential to simplify access, lower manufacturer costs, and improve adherence. But it also introduces new risks if the transition is not managed carefully.
To meet this moment, patient services providers must rise to the challenge of building flexible, tech-enabled, patient-first programs that combine the best of old and new. When done right, these solutions don’t just facilitate access. They empower patients to succeed on therapy and live healthier lives.