Key words:THE INNOVATION

Primary care clinicians report feeling “tethered to the electronic health record (EHR).”1 Trapped in a maze of unclear health insurance coverage criteria and unexpected prior authorizations (PA), short-staffed clinical teams spend hours uploading medical documentation, on hold with insurance plans, and waiting by the fax machine to process a PA or durable medical equipment (DME) order.

Responding to requests from our members for an “easy button,” the Michigan Collaborative for Type 2 Diabetes (MCT2D) developed the MCT2D Coverage Checker. This web-based tool provides preferred coverage, step therapy, and PA guidelines for type 2 diabetes (T2D) guideline-directed medical therapy (incretin mimetics and sodium-glucose cotransporter 2 [SGLT2] inhibitors) and continuous glucose monitoring (CGM) devices. Also, it identifies if a CGM order should be sent to a DME or a pharmacy. In cases where an entire class of medication is excluded from coverage (eg, weight management for obesity), Coverage Checker can help clinical teams avoid futile prior authorizations.

Coverage Checker encompasses roughly 75% of Michigan’s largest commercial, Medicare, and Medicaid insurance policies.2 An accompanying patient tool guides patients through understanding their plan’s diabetes medication and CGM coverage.

Since launching 36 months ago in early 2022, Coverage Checker has been downloaded and viewed over 174,000 times. “It’s like our bible,” one practice member noted. Another shared that the patient tools “have saved office staff time and are valuable resources, as the patient is empowered to take their healthcare into their own hands.”

WHO & WHERE

Nearly 1,400 physicians and their teams, across 396 primary care, nephrology, and endocrinology practices in Michigan, are enrolled in MCT2D, a Blue Cross Blue Shield of Michigan-supported Collaborative Quality Initiative to improve T2D care across Michigan. The MCT2D coordinating center has 8 full-time equivalent (FTE) staff, including 3 FTE human-centered designers and informaticists.

HOW

Participating MCT2D physicians submitted patient case summaries and needs assessments to MCT2D as required for their participation. The MCT2D design team analyzed nearly 1,000 participant submissions and transcripts from meetings with various practice stakeholders. This analysis validated the need for a solution to assist with T2D-related PAs.

In late 2021, an MCT2D informatics designer and the lead pharmacist partnered to develop an initial guide. The PDF guide was made available at mct2d.org, the organization’s e-mail newsletter, and distributed at collaborative-wide meetings.

The PDF tool quickly ranked in the top 1.5% of trafficked pages on MCT2D’s website.

An interactive, online version of the tool was co-designed and tested with a small group of MCT2D clinicians who met 4 times in early 2024. The human-centered design team engaged in a series of agile design sprints to develop a minimum viable product launched in May 2024. In a few clicks, any care team member can see a patient’s coverage eligibility, access plan-specific PA criteria to ensure more efficient approvals, and automatically generate required EMR documentation to include in chart notes. To maintain accuracy, the team performs quarterly reviews of formularies and medical policies and meets regularly with payors.

Since launching in 2024, it has expanded to include more plans and medications, with mobile app version launching in mid to late 2025.

LEARNING

The successful development of Coverage Checker would not be possible without organizational investment in diabetes care via population health quality improvement. The challenge of maintaining up-to-date coverage data has prompted the MCT2D team to develop more effective relationships across the payor landscape. Regular collaboration with payors has fostered greater accountability, improvements to coverage criteria, and streamlined approvals.

Received for publication December 23, 2024.Revision received February 25, 2025.Accepted for publication March 4, 2025.© 2025 Annals of Family Medicine, Inc.