5.16 Blood Glucose Testing

PharmaCare covers BGTS for patients who meet the following conditions:

• Blood glucose testing is deemed medically necessary; and
• They have completed a blood glucose monitoring training at a DEC or PCN
• A Confirmation of Training in Blood Glucose Monitoring has been faxed to Health Insurance BC (HIBC)

• BGTS are a benefit under Fair PharmaCare, Plan C (Income Assistance), Plan F (At Home Program) and Plan W (First Nations Health Benefits).
• BGTS are not covered under Plan B since routine medical supplies are to be provided to patients at no cost by the long-term care facility. Refer to the Home and Community Care Manual, Section 6, for details.
• Using another PharmaCare plan to submit PharmaCare claims for BGTS for individuals covered under Plan B is inappropriate. Such claims are subject to recovery.

• BGTS are reimbursed at their actual acquisition cost up to the PharmaCare maximum price for the product plus a dispensing fee (up to the PharmaCare maximum allowable fee).
• Consult the list of BGTS to determine the eligibility of particular strips for PharmaCare coverage and the PIN to be used to enter claims in PharmaNet.
• Pharmacists must use the specific PIN assigned to each strip when submitting a claim.

DECs and PCNs need submit an initial Confirmation of Training in Blood Glucose Monitoring to HIBC for their patients. Once the patient’s eligibility is entered on PharmaNet, the patient receives ongoing coverage of BGTS. 

If a patient’s Confirmation of Training in Blood Glucose Monitoring has not yet been entered on PharmaNet, the patient can present a Blood Glucose Test Strip – Coverage Voucher at the pharmacy for one-time provisional coverage of BGTS (see Provisional Coverage, below).

When a patient’s eligibility for BGTS is not yet in PharmaNet and the patient presents a Coverage Voucher, the pharmacy must fax a copy of both sides of the Coverage Voucher to HIBC at 250-405-3587.

Note that the First Nations Health Authority's private insurer will cover the first fill of BGTS for newly-diagnosed individuals covered under First Nations Health Benefits (Plan W), providing the BGTS is a PharmaCare benefit. For issues concerning coverage of BGTS for Plan W clients, contact the First Nations Health Benefits team at 1-855-550-5454.  

Patients can contact their prescriber, DEC or PCN for information on obtaining training and certification.

>> See the procedure below for Determining if a patient has a Confirmation ("Certificate") of Training

• PharmaCare Help Desk representatives may enter provisional (1 day) coverage on PharmaNet if the pharmacy faxes copies of both sides of the Blood Glucose Test Strip – Coverage Voucher to HIBC.
• A provisional certificate is subject to a $100.00 maximum.
• Provisional coverage is provided only once for an individual.
• Provisional coverage is limited to one fill.

PharmaCare applies an annual quantity limit of BGTS that will be reimbursed per patient per calendar year based on five categories of patients.

The categories are determined by the type of diabetes-related medication(s) a patient is taking, if any.

When a claim is submitted for BGTS, PharmaNet reviews all claims submitted in the previous 180 days for anti-hyperglycemic medications, whether or not the medications are covered by PharmaCare, and assigns the patient to one of five categories.

If a patient belongs to more than one category and is not using a CGM/FGM, the higher limit will apply.

Depending on a patient's medication history at the time a BGTS claim is submitted, a patient may belong to different BGTS categories within a calendar year. If a change in a patient's BGTS category occurs within the same calendar year, previous claims made during the year will be applied to their updated annual quantity limit. 

All BGTS purchased, regardless of coverage, count toward a patient's annual limit.

Patients using a CGM/FGM may also need to occasionally use blood glucose test strips. For example, confirmation of blood glucose results using BGTS may be required when a patient receives an error code on their CGM/FGM or when their symptoms do not match their CGM/FGM readings.

Exceptions to the annual quantity limit for BGTS

There may be exceptional clinical circumstances in which patients need additional test strips above their annual quantity limit.

Requests for coverage of additional strips, up to the maximums indicated below, can be made through the PharmaCare Special Authority process.

Additional test strips for a pediatric patient using a CGM/FGM may be requested at the time of initial CGM/FGM request or with a CGM/FGM renewal request (using the CGM/FGM Special Authority request form).

^{†Including but not limited to insulin secretagogues (e.g., sulfonylureas, meglitinides).
‡Including but not limited to: alpha-glucosidase inhibitors (e.g., acarbose), biguanides (e.g., metformin), dipeptidyl peptidase-4 inhibitors (DPP4I), incretin mimetics/glucagon-like peptide (GLP-1) agonists, sodium-glucose cotransporter 2 (SGLT2) inhibitors (e.g., canagliflozin), thiazolidinediones (TZDs), glucose-dependent insulinotropic polypeptide (GIP) and glucagon-like peptide-1 (GLP-1) receptor agonists (e.g., tirzepatide).}

The Diabetes Supplies web page provides the clinical criteria for coverage of additional strips, the Special Authority request form, information on the health care practitioners who can request coverage, and instructions.

PharmaCare covers a continuous glucose monitor (CGM) or a flash glucose monitor (FGM) for patients who meet the following conditions:

• The patient has diabetes mellitus (DM) and meets the minimum age requirement
  • For a CGM, is age 2 or older
  • For a FGM, is age 4 or older
• The patient requires multiple daily injections of insulin or insulin pump therapy as part of intensive insulin therapy
• The patient, family, or caregiver agrees to comprehensive and age-appropriate diabetes education by an interdisciplinary diabetes healthcare team and commits to regular follow-up

• CGMs/FGMs are a limited coverage benefit under Fair PharmaCare, Plan C (Income Assistance), Plan F (At Home Program) and Plan W (First Nations Health Benefits)
• Starting November 7th, 2023, patients with SA approval for a CGM or FGM will receive coverage for one brand of glucose monitoring devices (e.g., Dexcom CGM system or FreeStyle Libre FGM system). Current patients will have one year to switch between devices. New patients and existing patients requesting renewals need to select one glucose monitor in their SA request
• A prescriber must submit a Special Authority request for coverage and the request must be approved. With Special Authority in place, a CGM/FGM is fully covered

Note: Special Authority must be in place for anyone wanting PharmaCare coverage of a CGM/FGM, even if they were using a CGM/FGM before PharmaCare covered these.

• CGM/FGM supplies may be dispensed in up to 90-day intervals.
• Quantity limits per 90 days
  • For CGMs, patients are covered for 1 transmitter and 3 boxes of sensors (total 9 sensors); each sensor can be worn for 10 days
  • For FGMs, patients are covered for 7 sensors; each sensor can be worn for 14 days

• CGMs/FGMs are reimbursed at their actual acquisition cost up to the PharmaCare maximum price for the product plus a dispensing fee (up to the PharmaCare maximum allowable fee). For more information, see Section 5.7—Actual Acquisition Cost Policy.
• Consult the list of PINs to determine the eligibility of particular products for PharmaCare coverage and the PIN to be used to enter claims in PharmaNet
• Pharmacists must use the specific PIN assigned to each device component when submitting a claim

1. Call the PharmaCare Help Desk.
2. After selecting the PharmaCare Information Line option, select the Blood Glucose Certificate option.
3. Enter the patient’s 10-digit PHN, and press #.

​If a valid Confirmation of Training is on record, the recording will confirm this.

As an alternative to the procedure above, the pharmacist can send the transaction through PharmaNet, and then reverse it if adjudication indicates there is no valid certificate.

Submitting claims for strips within the patient’s annual limit or for which the patient or a third-party insurer will pay

Use the PIN indicated on the list as the “Regular (Within Annual Limit/Patient Pay)” PIN.

If the claim adjudication response is LO – Benefit maximum exceeded, the patient has exceeded their annual limit.

Submitting claims for strips above the patient’s annual limit

If the patient indicates they requested additional strips through their prescriber or a diabetes education centre or a primary care network, please contact the PharmaCare Help Desk to ask if Special Authority coverage is in place for additional strips.

If Special Authority is in place:

• Create a new claim with a new prescription number and use the Special Authority PIN.
  See Diabetes PINs.
  
  IMPORTANT: If Special Authority is in place, but you process the claim with the regular PIN instead of the Special Authority PIN, the cost of the claim will not count toward the patient's Fair PharmaCare deductible.

If Special Authority is not in place:

• Advise the patient that they can see their prescriber or visit a diabetes education centre or a primary care network if they believe they may be eligible for approval of additional strips,
  
  OR
   
• Submit the claim using the “Regular (Within Annual Limit/Patient Pay)” PIN

Submitting claims at the start of each calendar year

On January 1 of each  year, be sure to revert to using the “regular” PINs for all patients.

• Make sure a Special Authority is in place (1 year for initial coverage; 5 years for renewed coverage)

If a Special Authority is in place:

• Create a new claim with a new prescription number
• Use the Special Authority PIN. See Diabetes PINs.

If Special Authority is not in place:

• Advise the patient to see their prescriber