Expansion of PharmaCare Coverage for Insulin Pumps

Beginning July 3, 2018, the PharmaCare insulin pump program will be expanded, so age is not a barrier to insulin pump access in B.C.

Currently only people aged 25 or younger who meet eligibility criteria can receive PharmaCare coverage for insulin pumps. As of July 3, anyone who meets the eligibility criteria can work with their endocrinologist or diabetes specialist to apply for insulin pump coverage.

This expansion does not change any other existing pump coverage eligibility criteria, pump supply coverage, or insulin coverage.

To enable this expansion of insulin pump coverage, the province engaged in a competitive value process to find the best value for insulin pumps in B.C. The result of this process is a tiered approach, where new and existing insulin pump users who qualify for coverage will be provided the tier 1 device (the Omnipod system) at no cost, regardless of which PharmaCare plan they are covered under or what their deductible or family maximum is.

People with an exceptional clinical need, or for whom the tier 1 device is not suitable, can have their endocrinologist or diabetes specialist submit a request for exceptional coverage of the tier 2 device (the MiniMed pump) instead. This device may come with an out-of-pocket cost to the person, depending which PharmaCare plan they are covered under and what their deductible and family maximum are.

Until expanded coverage goes into effect on July 3, any special authority requests received for patients over age 25 will be held. These requests will be processed after July 3.

The new Special Authority form, patient information sheets, eligibility criteria, and supporting materials will be published on July 3.

More Information and Frequently Asked Questions

  • There will no longer be an age limit for PharmaCare coverage of insulin pumps.
    • Previously, only children and young adults 25 years old or younger were eligible for coverage.
    • As of July 3, people of any age will be able to apply for coverage of an insulin pump.
  • Coverage for insulin pumps will be offered in a tiered approach.
    • Previously, a person approved for insulin pump coverage received no direction from PharmaCare about which of the two available devices to purchase. The same level of coverage was provided for both the Omnipod system and the MiniMed pump.
    • As of July 3, a person will be approved for coverage of the Omnipod system. Only a person whose endocrinologist or diabetes specialist confirms that the Omnipod system is not suitable or there is a clinical requirement will receive coverage for the MiniMed pump.
  • The Omnipod system will be available at no cost to the patient.
    • Previously, the Omnipod system cost $6,300, and the MiniMed pump cost $6,600.
    • The cost for both pumps was covered 100% for people under Plan C (Income Assistance), Plan F (Children in the At Home program), and Plan W (First Nations Health Benefits). For Fair PharmaCare recipients, the person paid 100% of the cost required to reach their deductible, then PharmaCare paid 70% of the cost above their deductible, and 100% of any cost above their family maximum.
    • As of July 3, the Omnipod system will cost the patient $0, regardless of which PharmaCare plan they are covered under or what their deductible and family maximums are.
    • The MiniMed pump will remain priced at $6,600. A person approved for exceptional coverage of the MiniMed pump will receive 100% coverage if they are under Plans C, F, or W, while coverage amounts for Fair PharmaCare recipients will be subject to their deductible and family maximum.

A B.C. resident who is currently on multiple daily injections will be eligible for coverage of an insulin pump if:

  • They are covered under Fair PharmaCare, Plan C (Income Assistance), Plan F (Children in the At Home Program), or Plan W (First Nations Health Benefits), and
  • They have type 1 diabetes or another form of diabetes requiring insulin, and
  • They are checking their blood glucose at least 4 times per day and recording the results, and
  • They agree to comprehensive and age-appropriate diabetes education by an interdisciplinary diabetes health team and commit to regular follow up, and
  • They experience unpredictable swings in blood glucose levels, frequent unpredictable hypoglycemic episodes, or frequent unpredictable diabetic ketoacidosis.

A B.C. resident who is already using an insulin pump will be eligible for coverage of a replacement pump if:

  • They are covered under Fair PharmaCare, Plan C (Income Assistance), Plan F (Children in the At Home Program), or Plan W (First Nations Health Benefits), and
  • They have type 1 diabetes or another form of diabetes requiring insulin, and
  • They agree to ongoing diabetes education, and
  • Their A1c is 9.0% or less on two occasions (one result from within 1 month prior and another result from 4–6 months prior), and
  • They have not had more than one diabetic ketoacidosis episode in the past year.

Approval for replacement pumps will only be provided once every 5 years. If a person is currently using a pump that was not covered by PharmaCare, their device must be more than 4 years old and no longer under the manufacturer’s warranty in order to receive coverage for a replacement pump.

To obtain coverage:

  • The person speaks to their endocrinologist or diabetes specialist about whether an insulin pump is appropriate.
  • If the person meets the eligibility criteria, the physician will complete and submit a Special Authority request to PharmaCare.
  • PharmaCare Special Authority will review the request.
  • If approved, Special Authority will send an approval letter (including instructions on how to obtain the approved pump model) to the requesting physician.
  • The physician will provide a copy of this letter to the person.
  • The person will follow the instructions provided to order their pump, and provide a copy of the approval letter to the insulin pump vendor.
  • PharmaCare undertook a process to find the best value for insulin pumps. As a result, the device with the best possible price will be covered by default for all new and replacement pumps (tier 1). The other pump will be covered only in exceptional cases for those who need it (tier 2).
  • The tier 1 device is the Omnipod Personal Diabetes Manager CAT45E manufactured by Insulet Canada, and the tier 2 device is the MiniMed 630G pump manufactured by Medtronic Diabetes Canada.
  • A person who requests coverage and meets eligibility criteria will receive coverage for the tier 1 device.
  • For a person with exceptional clinical requirements better served by the tier 2 device, or for a person whose endocrinologist deems the tier 1 device unsuitable, exceptional coverage will be reviewed by PharmaCare Special Authority on a case-by-case basis in consultation with the  endocrinologist. The tier 2 device is only covered if this exceptional Special Authority approval is requested and granted.
  • Both insulin pump options were previously reviewed by PharmaCare and met all specifications required for listing.
  • Both perform the function of continuous insulin delivery, with differences in design elements and features.
  • There is no recognized therapeutic advantage to one device over the other.
  • If a person needs the tier 2 device (i.e., their endocrinologist determines that the tier 1 device has proven unsuitable or that the person has a clinical requirement not satisfied by the tier 1 device), their endocrinologist or diabetes specialist physician can request exceptional Special Authority coverage. PharmaCare Special Authority will review each request on a case-by-case basis and make a determination in consultation with the person’s physician.
  • If a person would prefer the tier 2 device, but does not have a clinical requirement or reason why they could not use the tier 1 device, PharmaCare will not provide coverage of the tier 2 device. The person can choose to purchase the tier 2 device at their own expense.

As of July 3, 2018:

  • B.C. residents approved for PharmaCare coverage will be able to obtain an Omnipod system at no cost.
  • Those approved for exceptional coverage of the MiniMed pump may have to pay out of pocket.
    • The cost of a MiniMed pump is $6,600.
    • For Plan C, F, or W beneficiaries, PharmaCare provides 100% coverage and there will be no cost to the person.
    • For Fair PharmaCare beneficiaries, the coverage amount depends on the person’s deductible and family maximum. This often results in an out-of-pocket expense at the time of purchase. (The person pays 100% of the cost required to reach their deductible, then PharmaCare pays 70% of the cost above their deductible, as well as 100% of any cost above their family maximum.)
  • If a person has an appointment with their endocrinologist or diabetes specialist physician before July 3, their physician may submit a special authority request before the effective date.
  • Any requests for adults 26 or older received before July 3 will be held and processed only after the effective date.
  • The updated special authority form will be available online on July 3, 2018.
  • After July 3, all requests must be submitted on the updated form.
  • PharmaCare cannot provide retroactive coverage of any device purchased without PharmaCare Special Authority approval.
  • When a person requires a new pump in the future (i.e., when the pump is more than 4 years old and no longer under manufacturer warranty), they can request PharmaCare coverage of a replacement device.
  • Coverage of insulins is not changing at this time.
  • If approved, insulin pump coverage is provided for the device itself. Insulins are covered separately.
  • PharmaCare covers the rapid-acting insulins used in insulin pumps, up to a maximum allowable cost.
  • Coverage of insulin pump supplies is not changing at this time.
  • PharmaCare continues to cover supplies used with any pump brand, regardless of whether the pump was covered by PharmaCare.
  • PharmaCare covers supplies such as infusion kits, cartridges, and pods. PharmaCare does not cover other supplies like batteries, adhesive pads, or pump covers.