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.
AND
The patient/family is checking blood glucose at least 4 times per day and recording the results.
AND
The patient/family agrees to comprehensive and age-appropriate diabetes education by an interdisciplinary diabetes healthcare team and commits to regular follow up.
AND
   The patient has frequent unpredictable hypoglycemic episodes.
   OR
   The patient has frequent unpredictable diabetic ketoacidosis episodes.
   OR
   The patient has unpredictable swings in blood glucose.

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.
AND
The patient/family agrees to ongoing diabetes education.
AND
The patient’s A1c is less than or equal to 9.0% on two occasions: one within 1 month prior to application and another 4–6 months prior.
AND
The patient has had no more than one diabetic ketoacidosis episode in the past year.

Special Authority coverage renewal for a subsequent pump will only be considered once every five years.

Practitioner Exemptions

  • None

Special Authority Request Form(s)