BC PharmaCare now covers insulin-infusion pumps for children and adolescents with Type 1 diabetes

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Effective November 17, 2008, the BC PharmaCare program has added coverage of insulin-infusion pumps for children and adolescents with Type 1 diabetes. Previously only insulin pump supplies were covered.

What are the age definitions for this new coverage?

This age bracket is defined as those 18 years of age and younger. 

What criteria does a child/adolescent have to meet to be covered for an insulin pump and supplies?

  • Children must be 18 years of age or younger with Type 1 diabetes or another form of diabetes requiring insulin.
  • They are covered under Fair PharmaCare or PharmaCare Plan C (B.C. Income Assistance Recipients). BC’s Ministry of Health website also provides additional information.
  • They must meet the medical criteria for insulin pump therapy as determined by a diabetes physician.

How does someone obtain provincial coverage for these devices?

If a diabetes physician specialist determines that a member’s child meets the medical criteria for a pump, the specialist can submit a Special Authority request to PharmaCare. The member will need to receive an approval letter from PharmaCare which he/she can then take to an approved vendor for the purchase.

Are insulin pump purchases retroactively covered?

No. Purchases made before approval of coverage is received will not be covered.

How much does the province cover?

  • If the plan member and their dependent child are covered under the Fair PharmaCare plan, PharmaCare covers 70% of costs above the deductible and 100% of costs above their family maximum.
  • For individuals on Plan C (B.C. Income Assistance), PharmaCare covers 100%
  • PharmaCare covers only one insulin pump every five years and does not cover repairs
  • The plan member must register for Fair PharmaCare, and have the Special Authority approval letter, before purchasing an insulin pump to ensure that maximum coverage is received. PharmaCare has indicated that Funding will not be retroactive for pumps purchased prior to qualifying for provincial coverage.

Does the province cover insulin pump supplies as well?

Yes, PharmaCare covers infusion sets/kits and insulin pump reservoirs/cartridges, but does not cover batteries, battery caps, adhesive pads, or similar items. For a full definition of what is covered under “supplies,” please refer to the provincial websites for additional information and specific definitions of coverage.  

How is Sun Life administering claims for these devices?

  • With this new provincial coverage, plan members whose dependent children qualify under the provincial plan (if the age category and medical requirement are met), must first seek reimbursement from the province for the purchase of these devices prior to making a claim to Sun Life.
  • Not all group plans cover the expenses for the purchase of insulin-infusion pumps. If your Sun Life group plan covers these expenses and the dependent is not eligible for coverage by the province under the Special Authority program, then claims for expenses can be submitted under your Sun Life plan. Please have plan members refer to their plan member booklet.

We’ve provided a communication for your plan members with this information.

Questions?

For detailed information on this provincial coverage, or how to apply, please contact the provincial health plan directly: www.health.gov.bc.ca under Contact Us for a full telephone listing.

For information on how this coverage may affect your group plan, contact your Sun Life Financial group benefits representative.