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APhA 2025: Cost, Coverage, and Clinical Evidence for CGM Use in Non-Insulin Users With Type 2 Diabetes
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Two pharmacists at the 2025 APhA Annual Meeting debate the role of continuous glucose monitoring (CGM) for non-insulin users, highlighting evolving guidelines, emerging clinical evidence, cost and coverage challenges, and the need for further research to justify widespread adoption.
Continuous glucose monitoring (CGM) technology is rapidly evolving, offering potential benefits for a broader range of patients beyond those using insulin. During the 2025 American Pharmacists Association (APhA) Annual Meeting & Exposition in Nashville, Tennessee, Heather Roth, BSPharm, and Heather Johnson, PharmD, BCACP, debated the role of CGM in patients with type 2 diabetes who are and are not on insulin in the session titled “Moonshine vs Tennessee Wine: Debate on Controversies in Diabetes.” Their discussion highlighted emerging recommendations from key organizations, the growing body of clinical evidence for each indication, and ongoing challenges related to coverage, cost, and real-world implementation.
Evolving Guidelines and Access
The American Diabetes Association (ADA) has updated its recommendations to consider CGM for individuals with type 2 diabetes who are treated with glucose-lowering medications other than insulin, explained Heather Roth, BSPharm, a clinical pharmacy specialist at Corewell Health in Grand Rapids, Michigan. The rationale behind this guidance is rooted in the increasing affordability and accessibility of CGM devices, along with their ability to empower patients in managing their condition. Roth emphasized that the rapid pace of technological advancement has led to greater adoption of CGM, even among patients who may not traditionally be prescribed such devices.
Woman using continuous glucose monitoring system at home. Image Credit: © Lubos Chlubny - stock.adobe.com
“These technologies are improving and they're getting lower cost, so access is increasing, and therefore a lot of folks have been using them,” Roth said during the APhA session.
Additionally, the American Association of Clinical Endocrinology (AACE) has echoed the potential benefits of CGM across a broad spectrum of diabetes patients. Their guidelines suggest CGM may be particularly useful for individuals with problematic hypoglycemia, including those with hypoglycemia unawareness, elderly patients, and those on sulfonylureas. Furthermore, AACE supports the use of CGM in gestational diabetes, recognizing the potential for improved glycemic control in pregnancy.
“AACE also said diabetes technology is rapidly changing and improving, and they even call out that it can be beneficial for all of those living diabetes,” Roth said. “Now I know that insulin is one of those agents that has the highest risk for high levels, but there's other patients out there, and we work with these patients too.”
Another key recommendation from ADA and AACE is the integration of CGM with virtual coaching and online platforms. This approach has been shown to enhance glycemic outcomes by providing real-time feedback and behavioral support, a factor that could be crucial in maximizing the benefits of CGM for non-insulin users, according to Roth.
Clinical Evidence Supporting CGM Use
Clinical trials have demonstrated the benefits of CGM in reducing A1c levels, improving time in range, and minimizing hyperglycemia in patients using insulin. However, the evidence for CGM in non-insulin users is still developing. Roth pointed to emerging studies that suggest CGM may help non-insulin users achieve and maintain glycemic targets by providing real-time insights into how lifestyle factors—such as diet and exercise—impact blood sugar levels.
Despite this, Johnson, an assistant professor of clinical pharmacy and family medicine in West Virginia University School of Pharmacy in Morgantown, raised concerns about the current strength of the evidence of CGM in patients not on insulin. She cited a 2019 meta-analysis that included 27 randomized controlled trials with nearly 4000 patients using insulin, demonstrating the robust data around CGM’s benefits in reducing A1c and preventing hypoglycemia. However, similar large-scale, high-quality trials are lacking for non-insulin users. While early data are promising, these data have yet to establish the same level of clinical justification seen in insulin-treated populations.
“My argument is just going to be that we don't have the evidence to justify it yet,” Johnson said. “If we look in our CGMs and started out just type 1 diabetes, then we got evidence for type 2 on basal-bolus insulin, then we finally got evidence just bolus alone, but we just don't know yet if it's beneficial without insulin.”
Johnson further emphasized that CGMs most significant advantage lies in preventing hypoglycemic crises, which is a major concern for insulin users. Since non-insulin users generally have a lower risk of severe hypoglycemia, the necessity of CGM in this patient population remains uncertain.
Emerging CGM Technologies and Real-World Considerations
A major driver of CGM adoption among non-insulin users is the growing availability of OTC CGM devices. Roth highlighted several new CGM products designed specifically for non-insulin users, such as the Dexcom Stelo and Abbott Libre Rio. These devices cater to individuals with type 2 diabetes and even to those seeking to optimize overall health and wellness.
However, the broader availability of CGM does not automatically equate to universal benefit. Roth acknowledged that CGM is not necessary for every patient, emphasizing that targeted use in specific populations—such as those struggling with glycemic control—may be the most appropriate approach. The effectiveness of CGM is also highly dependent on patient education and engagement. If patients do not actively use the data to adjust their behaviors, the benefits may be limited.
Challenges of Cost and Coverage
Patient using a digital glucose monitor to check their blood sugar levels. Image Credit: © ArpPSIqee - stock.adobe.com
One of the most significant barriers to widespread CGM use remains cost and insurance coverage. Johnson pointed out that Medicaid and other insurers often impose strict coverage criteria, requiring frequent insulin use before approving CGM. She argued that resources may be better spent expanding coverage for insulin users who still face access barriers rather than extending CGM to non-insulin users without clear evidence of benefit.
Moreover, Johnson raised a fundamental question: If traditional blood glucose monitoring (ie, fingerstick testing) has not shown a significant A1c reduction in non-insulin users, how can CGM—which provides more frequent readings—be expected to deliver a different outcome? While CGM provides a wealth of data, its impact on long-term outcomes largely depends on how patients and health care providers utilize that information.
“What if we connect these patients with pharmacists? What if there's coverage for that? Because we know they have these data, and if they use it to modify physical activity, medications, meal plans, then you may see that improvement in A1c, but if they don't have that connection, there's not necessarily a benefit in pricking your finger or wearing a device 24/7,” Johnson said.
The Future of CGM in Non-Insulin Users
As diabetes technology continues to advance, the role of CGM in non-insulin users will likely become clearer. Future research should focus on demonstrating measurable benefits, particularly in terms of long-term glycemic control, quality of life, and cost-effectiveness. Additionally, expanding pharmacist involvement in CGM interpretation and diabetes management could help bridge the gap between data collection and actionable interventions.
Ultimately, CGM represents a valuable tool in diabetes care, but its optimal use in non-insulin users remains an open question. While early evidence suggests potential benefits, robust clinical trials and thoughtful implementation strategies are needed to ensure that CGM is used effectively and efficiently in the broader diabetes population.
“It's always going to come back to the money,” Johnson said. “CGMs are pretty expensive. Is that where we want somebody to spend their money? Or would it be better spent on having less processed foods? We know that's going to have a significant impact on diabetes. Insurance coverage is also important. I know in my state [of West Virginia], we're still trying to get Medicaid to do basal insulin only. You still have to do 3 times a day with insulin, and so for me, I would prefer to focus on that, and then we can move on to patients without insulin.”
