Limited Coverage Medical Supplies—Insulin Pumps

Instructions

  • Requests must be completed by an endocrinologist or a specialist physician with experience in managing pumps in children and adolescents.
  • The physician should complete Special Authority Request form #5375 (below) for initial and subsequent/renewal coverage.
  • Coverage is for one insulin pump in a five year period.

Additional Information:

Note: If a patient's current pump was not funded by PharmaCare, coverage of a subsequent pump will be considered if the pump is more than four years old and the manufacturer warranty has expired.

Product

Insulin pump (continuous subcutaneous insulin infusion)

Special Authority Criteria Approval Period

Initial Pump:

Patient is 25 years of age or younger

AND

Patient is diagnosed with type 1 diabetes or another form of diabetes requiring insulin

AND

Patient/family is checking blood glucose at least 4 times daily and recording results.

AND

Patient and/or family agrees to age-appropriate ongoing diabetes education

PLUS

Patient has frequent hypoglycemic episodes

OR

Patient has frequent diabetic ketoacidosis episodes

OR

Patient has unpredictable swings in blood glucose

Subsequent Pump/Renewal:

Patient is 25 years of age or younger

AND

Patient is diagnosed with type 1 diabetes or another form of diabetes requiring insulin

AND

Patient and/or family agrees to age-appropriate ongoing diabetes education

AND

A1C is less than or equal to 9.0% on two occasions; one within 1 month prior to application and another 4 - 6 months prior.

AND

Patient has had no more than one diabetic ketoacidosis episode in the past year.

Not applicable

Practitioner Exemptions

  • None

Special Authority Request Form(s)