5.17 Insulin Pumps

General Policy Description

PharmaCare covers insulin pumps to ensure that cost is not a barrier to the use of an insulin pump for patients with diabetes requiring the use of regular or rapid-acting insulin.

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Policy details

Patient and plan eligibility

Insulin pump coverage is available to patients who:

• Have type 1 diabetes or another form of diabetes requiring the use of regular or rapid-acting insulin, and
• Are covered under Fair PharmaCare, Plan C (Income Assistance), Plan F (Children in the At Home Program), Plan W (First Nations Health Benefits), or Plan B (Permanent Residents of Licensed Long-term Care Facilities), and
• Have been confirmed as meeting the medical criteria for coverage by their diabetes physician, and
• Have received Special Authority (SA) approval for coverage

Patients should register for Fair PharmaCare before applying for insulin pump coverage. This ensures the patient knows what their Fair PharmaCare deductible is in advance. Eligible prescription and medical device/supply costs already incurred during the year would count towards their deductible before their insulin pump purchase.

Coverage

PharmaCare coverage is limited to one insulin pump every five years (or after four years if the pump was previously covered by an organization other than PharmaCare, e.g., a private insurer).

PharmaCare covers insulin pumps in a tiered approach:

For first pumps, approved patients receive coverage for the tier-1 product, unless a significant clinical requirement prevents the patient from using the tier-1 product

Exceptional coverage of a tier-2 product must be approved by SA, based on the patient’s clinical requirement, as detailed by the patient’s endocrinologist

For a replacement pump, coverage may be given for a tier-2 pump, if this is the product the patient previously used. Best practice is to keep patients on the same type of pump, so their condition is not destabilized. Physicians should note that the patient is currently stable on the product, in the Rationale field on page 2 of the insulin pump Special Authority request (HLTH 5375)

Note: If the patient is currently using a tier-2 pump regardless of who paid for it, the pump is considered a replacement pump and not a first pump (i.e., even though it is the first pump covered by PharmaCare). Refer to Patients with existing insulin pumps not covered by PharmaCare below.

Only the makes and models of insulin pumps approved by PharmaCare are eligible for PharmaCare coverage, and only when the insulin pump is purchased from an approved vendor, as identified for the patient and their endocrinologist in their SA approval confirmation letter.

PharmaCare covers a maximum price for each insulin pump make and model, with no dispensing fee.

Tier-1 pumps are available at no cost regardless of the PharmaCare plan. Coverage of tier-2 pumps is subject to the rules of the patient’s PharmaCare plan. For example, if a patient is covered by:

• Plan C (Income Assistance), PharmaCare covers 100%
• Plan F (Children in the At Home Program), PharmaCare covers 100%
• Plan W (First Nations Health Benefits), PharmaCare covers 100%
• Plan B (Permanent Residents of Licensed Long-term Care Facilities), PharmaCare covers 100%
• Fair PharmaCare, PharmaCare covers 70% of eligible costs above the patient’s deductible and 100% of eligible costs above their family maximum (subject to plan rules)

Important: Patients who are not covered by Plan C or who are covered by Plan C temporarily (i.e. will no longer need income assistance in the future) should register for Fair PharmaCare before purchasing an insulin pump.

Coverage requirements

PharmaCare coverage of insulin pumps requires prior SA approval by PharmaCare. Approval is provided on a case-by-case basis.

SA approval for insulin pump coverage cannot be provided retroactively.

SA approval for the purchase of an insulin pump may be requested once every five years on behalf of an eligible patient. SA requests must be submitted by the referring specialist physician or endocrinologist.

Refer to Insulin Pump Special Authority for the medical criteria for coverage, SA request form, and instructions about how to secure coverage.

PharmaCare sends a letter confirming or denying coverage to the referring specialist physician or endocrinologist. The physician must provide a copy of the approval letter to the patient.

The patient must provide a copy of the SA approval letter to the insulin pump vendor prior to or at the time of purchase.

Insulin pump claims for patients who do not have PharmaCare SA approval will not be paid by PharmaCare.

Patients with existing insulin pumps not covered by PharmaCare

Patients with an existing insulin pump that was not covered by PharmaCare may be eligible for PharmaCare coverage if:

• They meet the patient and plan eligibility criteria,
• They meet the medical criteria for a subsequent insulin pump, and
• Their current pump is four or more years old, and
• The manufacturer's warranty for their current pump has expired

The patient’s specialist physician or endocrinologist must submit a General Special Authority request (PDF, 656KB) to PharmaCare requesting coverage.

The patient must contact their insulin pump manufacturer for a letter confirming the warranty expiry date. The physician must include this proof of warranty expiry with the SA request.

Reimbursement

Insulin pumps are reimbursed at the retail price up to the PharmaCare maximum allowable cost for the pump, with no dispensing fee.

Insulin pump repairs and replacement

PharmaCare does not cover insulin pump repairs. Manufacturers warranty their pumps for the five-year term.

PharmaCare does not cover insulin pump replacement prior to the end of the five-year period since coverage for a patient’s last pump was issued.

Insulin pump repairs and/or replacement of broken pumps are subject to the terms of the manufacturer’s warranty during the warranty period. The patient should refer all enquiries about pump repair and replacement to the vendor from which the pump was purchased.

Lost or stolen insulin pumps

Replacement costs for stolen or lost insulin pumps are not covered by PharmaCare.

Information for insulin pump vendors

A copy of the PharmaCare letter confirming SA approval for insulin pump coverage must be obtained from the purchaser and maintained on file. This letter will identify the model of pump that the patient has coverage for.

Insulin pump claims for patients who do not have PharmaCare SA approval for insulin pump coverage will not be paid by PharmaCare.

Insulin pump vendors must use the correct Product Identification Number (PIN) for the insulin pump that the patient has been approved for, as identified in the SA confirmation letter.

Information on connection to PharmaNet and online claims payment processes, as well as the processing of manual, paper based PharmaCare claims, is in the PharmaCare Claims for Insulin Pump Vendors Quick Guide (PDF, 1.2MB).

Questions and answers

What if I encounter problems using a pump instead of regular injections?

Speak to your endocrinologist or diabetes specialist. If, in consultation with your specialist, it is determined that you cannot continue using a pump, you may be able to return it. Vendors may allow you to return the pump for a refund within 90 days of purchase. In this case, the vendor will reverse the PharmaCare claim and refund any portion of the cost you paid.

What if my pump stops working after the five-year period is up?

If your pump is beyond economical repair, contact the vendor of your pump and ask for a letter confirming your warranty expiry date. Take the letter to your endocrinologist or specialist physician, who will include the letter with a new SA request to PharmaCare.

Tools and resources

• List of eligible insulin pumps and their PINs 
• List of eligible insulin pump supplies and their PINs
• Special Authority criteria for insulin pumps and request form