Limited Coverage Medical Supplies—Insulin Pumps
Instructions
- Requests must be completed by an endocrinologist or a specialist physician with experience in managing insulin pump therapy.
- The physician should complete Special Authority Request form 5375 for initial and subsequent/renewal coverage.
- Coverage is provided for one insulin pump every five years.
- If a patient's current pump was not covered by PharmaCare, coverage of a subsequent pump will be considered if the patient’s existing pump is more than four years old and the manufacturer's warranty has expired.
Additional Information:
Product
Insulin pump (continuous subcutaneous insulin infusion)
Special Authority Criteria | Approval Period |
---|---|
INITIAL PUMP The patient has type 1 diabetes or another form of diabetes requiring insulin. |
If approved, the Special Authority coverage is active for six months. The patient must obtain their pump within six months of receiving Special Authority coverage. |
SUBSEQUENT PUMP/RENEWAL The patient has type 1 diabetes or another form of diabetes requiring insulin. |
Special Authority coverage renewal for a subsequent pump will only be considered once every five years. |
Practitioner Exemptions
- None