5.17 Insulin Pumps

[July 3, 2018: Removal of age restriction for insulin pump coverage]

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.

Policy Details

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), or Plan W (First Nations Health Benefits), and
  • Have been confirmed as meeting the medical criteria for coverage by their diabetes physician, and
  • Have received Special Authority approval for coverage

Patients are encouraged to register for Fair PharmaCare before applying for insulin pump coverage. This ensures the patient knows what their Fair PharmaCare deductible is in advance and that all eligible prescription and medical device/supply costs already incurred during the year have been counted towards their deductible before their insulin pump purchase.

PharmaCare coverage is limited to one insulin pump every five years.

PharmaCare covers insulin pumps in a tiered approach:

  • All approved patients will receive coverage for the first tier product, regardless of whether it is an initial or replacement pump, unless there is a significant clinical requirement preventing the patient from using the first tier product. 
  • Exceptional coverage of the second tier product will be provided if the patient’s clinical requirement, as detailed by the patient’s endocrinologist, is assessed and approved by the Special Authority department.

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 Special Authority approval confirmation letter.

Coverage will not exceed the PharmaCare maximum price for a particular insulin pump make and model, with no dispensing fee.

Coverage is subject to the rules of the patient’s PharmaCare plan. For example:

  • if a patient is on Plan C (Income Assistance), PharmaCare covers 100%.
  • if a patient is on Plan F (Children in the At Home Program), PharmaCare covers 100%.
  • if a patient is covered under Plan W (First Nations Health Benefits), PharmaCare covers 100%.
  • if a patient is covered under the Fair PharmaCare plan, PharmaCare covers 70% of costs above the patient’s deductible and 100% of costs above their family maximum.

Important: Patients should register for Fair PharmaCare before purchasing an insulin pump.

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

Special Authority approval for insulin pump coverage cannot be provided retroactively.

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

The Insulin Pump Special Authority web page provides the medical criteria for coverage, the Special Authority 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 for use in purchasing the approved insulin pump.

The patient must provide a copy of the Special Authority 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 Special Authority approval will not be paid 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 Special Authority request 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 Special Authority request.

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

PharmaCare does not cover insulin pump repairs.

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.

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

A copy of the PharmaCare letter confirming Special Authority 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 Special Authority 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 Special Authority confirmation letter.

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

 

Questions and Answers

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.

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 Special Authority request to PharmaCare.

 

Tools and Resources