Ontario has extended its provincial coverage of insulin-infusion pumps for individuals with Type 1 diabetes

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From September, 2008, Ontario has covered insulin-infusion pumps and supplies for adults - defined as those over 19 years of age. Previously, only children and youth under the age of 19 were eligible. This extension of coverage now provides continuous provincial funding.

Who is eligible for this new provincial coverage?

In Ontario individuals with Type 1 diabetes (as determined by a physician) who meet the criteria for funding under the Assistive Devices Program, (ADP) are eligible for coverage of these devices.

 

What determines someone’s eligibility for the ADP coverage?

If someone is over 19 years of age with Type 1 diabetes and is unable to achieve blood sugar control with multiple daily injections of insulin and is interested in the pump option, he/she must be assessed by a specialized team of diabetes professionals who will determine if pump therapy is feasible. This team also determines eligibility for ADP funding assistance.

The ADP is currently registering these diabetes teams across the province and training them on how to assess insulin pump eligibility.

Please refer to the Ontario Ministry of Health & Long-Term Care for more detailed information and instructions on how to apply.

 

Does the province cover insulin pump supplies as well?

Yes, $2,400 is allotted annually for the purchase of associated supplies and is paid out quarterly to the eligible individual.

 

How is Sun Life administering claims for these devices?

  • Plan members and dependents who qualify for this benefit under the provincial plan (if the age category and medical requirements are met), must first apply to the province for coverage of the device.
    • If the province approves the individual’s application, 100% of the price of the insulin pump cost will be paid to the vendor by ADP.
    • If the coverage is declined by the province, eligible expenses can be submitted to Sun Life. 
  • Adults with Type 1 diabetes must qualify for provincial coverage (by meeting the clinical criteria for funding under ADP first) before purchasing these devices. Funding will not be retroactive for pumps purchased prior to qualifying for provincial coverage.
  • These devices must be prescribed by a physician for a plan member or covered dependent.
  • 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 plan member or covered dependent is not eligible for coverage by the province, then claims for expenses can be submitted under their Sun Life plan. Please have 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 and how to apply, please contact the provincial health plan directly through the Ontario Assistive Devices Program at 1-800-268-6021 or the provincial website http://www.health.gov.on.ca.

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