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Financial Assistance and Insulin Pump Coverage...

 

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In memory of "Pumper Paul" whose dedication and drive brought us the first insulin pump bill in Canada


The fight for insulin pump coverage in all provinces across Canada has been going on for too many years! We are finally seeing the results of dedication and drive by people throughout this country but we still have a ways to go to see equity throughout the country. We continue to fight to ensure that all provinces cover insulin pumps for people of all ages. Children are our first step but not the last. We will all continue to push to see that EVERYONE who wishes to use an insulin pump in Canada will be able to do so

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Financial Assistance

Diabetes is a costly disease in so many ways. Trying to fight complications can be a financial burden that often is too much to carry. Sadly it is the poorest in our world who stand the highest chance of experiencing complications. Some  provinces and states in North America offer  help  to cover the costs of such items. That is still not enough. There are those of us in Canada who are and will continue to lobby various government agencies so that one day there is no longer this gap and everyone living with diabetes will have equal access to the best methods of care. 

 

Registered Disability Savings Plan from the government of Canada offers eligible claimants annual grant money that can later be used to offset some of the costs of diabetes supplies. This plan is similar in principal to an RRSP but for the assistance of medical expenses and only available to those who qualify for the Disability Tax Credit.

 

Provincial programs

 

British Columbia offers a PharmaCare program. Benefits and coverage under this program depend on income level. They do extend to all insulin on its formulary as well as insulin pump supplies for all ages under a two tiered system.

 

Manitoba will cover insulin pumps and supplies for children in their province. For more information, contact Diabetes Education Resource for Children and Adolescents (DER-CA) at 204-787-3011

 

New Brunswick financial assistance is for insulin coverage is limited to those receiving income support or low-income seniors. They only offer coverage to those insulins listed on their provincial formularies unless special authorization is given. Insulin pumps are now covered for those with type 1 diabetes up to 25 years of age.

 

Newfoundland and Labrador has an Assurance Drug Plan that offers protection against the financial burden of eligible high drug costs, whether from the cost of one extremely high-cost drug or the combined cost of different drugs. Depending on their income level, individuals and families will be assured that their annual out-of-pocket costs for eligible drugs will be capped at a percentage of their net family income.

Annual Income (net) Maximum % of Income to Spend on Eligible Drug Costs
$0 - $39,999 5%
$40,000 - $74,999 7.5%
$75,000 to $149,999 10%
 

Applications are available in physician’s offices and pharmacies as well as on-line at www.gov.nl.ca/health .Insulin pumps and supplies are covered for those under 25 years of age.

 

Nova Scotia has a Diabetes Assistance Plan which covers test strips, lancets, syringes and insulin listed on its formulary. This plan is designed to assist low-income families and people who are under the age of 65 and have no other drug coverage. Registration is underway for the Diabetes Assistance Program. Registration forms and information booklets are available by calling the Nova Scotia Diabetes Assistance Program. Information is also available on the Department of Health website. Forms and booklets can also be found in doctors' offices, pharmacies, and diabetes centres. Insulin pumps and supplies are covered for those under 25yr.

 

Ontario has two provincial drug programs that work the same way. The Ontario Drug Benefits Program and the Trillium Drug Plan both offer insulin coverage for families meeting the provincial criteria. Insulin covered only includes those listed on the provincial drug formulary. The Ontario government provides assistance for insulin pumps and supplies for children and adults.

 

Saskatchewan covers syringes and lancets for people with diabetes.  Insulin pumps and supplies are covered for children up to 18 years.

 

The situation in the Yukon and other territories remains somewhat unique. Many people living in the north receive 100% coverage of all insulins, pumps and pump supplies under the Non-Insured Health Benefits plan (NIHB). For those not covered under NIHB, there are different policies for the different territories. In the Yukon for example, all insulins except Levemir® are covered. They also cover pumps and pump supplies. To have your pump paid for, you must have an application filled that gives details of your case history stating your failure on MDI, evidence of your commitment and competence to use the pumps, as well as support for initiation and follow up therapy. Requests based on life style choices will not be considered. These requests must be signed by an endocrinologist. There are no specialists in the North. Patients seeking the support of doctors such as endocrinologists must go to major centres such as Vancouver, Edmonton, and Winnipeg to have their pumps prescribed

 

Provinces offering pump coverage

 

Alberta

Alberta will be providing insulin pump coverage to all residents with type 1 diabetes as of 2013.  Individuals must:

 

  • Be a resident of Alberta, eligible for coverage under the Alberta Health Care Insurance Plan.

  • Be diagnosed with Type 1 diabetes and be under the care of a physician or nurse practitioner for the condition.

  • Meet the clinical criteria established by Alberta Health Services for the IPT Program.

  • Follow steps outlined in the IPT Program for new or existing IPT users.

 

For more information contact your health care provider or go to the Alberta government website.

 

 

British Columbia:

Effective July 3, 2018 British Columbia will provide insulin pump and supply coverage for qualifying residents under a new two-tiered approach. 

Who is eligible for coverage?

Insulin pump coverage is available to those who:
have Type 1 diabetes or another form of diabetes requiring insulin, and
are covered under Fair PharmaCare or PharmaCare Plan C (B.C. Income Assistance Recipients), and
whose diabetes physician confirms that they meet the medical criteria.

How much will PharmaCare cover?

Under Tier 1, PharmaCare covers 100% of the cost of an Omnipod and supplies every five years subject to the rules of your PharmaCare plan.

Under Tier 2, PharmaCare will cover a portion of a tubed (Medtronic) insulin pump IF this pump is prescribed by your doctor and approved by special authorization.

Important: Be sure to register for Fair PharmaCare before purchasing an insulin pump to ensure you get maximum coverage.

How do we obtain coverage?

The first step is to speak to your diabetes physician specialist. If you meet the medical criteria for coverage of a pump, the specialist will submit a Special Authority request to PharmaCare.


When your physician specialist requests coverage, you will need to sign a form confirming that they are committed to blood glucose monitoring, to the safe and appropriate use of the insulin pump and to ongoing age-appropriate diabetes education.

If the request is approved, we will send an approval letter to your specialist's office. Your specialist will give you a copy of this letter to take to the insulin pump vendor of your choice.

Important: Be sure to wait for the approval letter before purchasing the insulin pump. PharmaCare cannot provide retroactive coverage for purchases made before approval is confirmed.

What if I encounter problems using a pump instead of regular injections?

Speak to your 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. Some vendors may allow you to return the pump for a refund in the first 90 days after purchase. In this case, the vendor will reverse the PharmaCare claim and refund any portion of the cost you paid.

How often will PharmaCare cover a new pump?

PharmaCare covers only one insulin pump every five years and does not cover repairs.

You may want to check that your home insurance covers any damage to the pump that is not covered under the manufacturer warranty.

What if my pump stops working after the five year period is up?

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 diabetes physician. Your specialist will include the letter from the vendor with the Special Authority request to PharmaCare.

What if we already own an insulin pump that was not covered by PharmaCare?

PharmaCare coverage is available if you meet the medical criteria for a subsequent pump, your current pump is four or more years old and the manufacturer's warranty has expired.

Your specialist can submit a Special Authority request to PharmaCare for coverage.

Contact your pump vendor for a letter confirming your warranty expiry date. Your specialist will include this proof that your warranty is about to expire with the Special Authority request.

Who is eligible for coverage of Insulin Pump Supplies?

Individuals of any age who are covered by the Fair PharmaCare Plan, Plan C (Income Assistance Recipients) or Plan F (At Home Program) are eligible for coverage of certain insulin pump supplies. This coverage is available whether or not your pump was covered by PharmaCare. PharmaCare pre approval is not needed for insulin pump supplies.

Which supplies are covered?

PharmaCare covers infusion sets/kits and insulin pump reservoirs/cartridges as shown on our Insulin Pump Supplies page. PharmaCare does not cover batteries, battery caps, adhesive pads, etc.

Where should I buy my insulin pump supplies?


You can buy insulin pump supplies from any pharmacy and some approved vendors in British Columbia. All pharmacies and approved vendors can submit claims to PharmaCare.


Other Diabetes Supplies


Blood Glucose Test Strips:  PharmaCare covers blood glucose test strips for individuals covered under Fair PharmaCare, Plan C (Income Assistance) and Plan F (At Home Program). PharmaCare covers your blood glucose test strips if:

blood glucose testing has been deemed medically necessary for you; and

you have a Certificate of Training issued by a Diabetes Education Centre.

Your Diabetes Education Centre will provide you with a printed certificate (in a wallet card form) and fax your information to PharmaCare.
Usually, a Certificate of Training gives you permanent PharmaCare coverage of testing strips. However, if the Diabetes Education Center enters an end date on your certificate (for instance, if you have gestational diabetes), coverage of testing strips is only for the period shown on your certificate.

Needles and syringes: PharmaCare covers needles and syringes if you have insulin-dependent diabetes and you are covered under Fair PharmaCare, Plan C (Income Assistance) and Plan F (At Home Program). You do not need a Certificate of Training from a Diabetes Education Centre to qualify for this coverage.
For needles and syringes for insulin therapy, PharmaCare covers the regular retail price but does not cover a dispensing fee.

Insulin: PharmaCare covers insulin if you are covered under Fair PharmaCare, Plan B (Permanent Residents of Residential Care), Plan C (Income Assistance) and Plan F (At Home Program). You do not need a Certificate of Training from a Diabetes Education Centre to qualify for this coverage.
PharmaCare covers most insulin up to the regular retail price but does not cover a dispensing fee.
from http://www.health.gov.bc.ca/pharme/medsup.html and http://www.newsroom.gov.bc.ca/2014/02/bc-announces-more-support-for-diabetes-management.html

 

Also see the provincial website.

Manitoba

Will cover insulin pumps and supplies for children in their province. For more information, contact Diabetes Education Resource for Children and Adolescents (DER-CA) at 204-787-3011

 

Eligibility criteria for the provinces new Manitoba Pediatric Insulin Pump Program include the following:  

Applicant is under 18 years of age Applicant has Type 1 diabetes

Completed discussion between child (if applicable), family and DER-CA team on appropriateness of insulin pump therapy

Home blood glucose monitoring a minimum of 4/day with results recorded

Regular attendance at DER-CA (minimum 3/year)

No more than 1 episode of diabetic ketoacidosis in previous 12 months

Three most recent HbA1C < 10%    

Eligibility for the reimbursement program involves an evaluation process and working closely with the DER-CA team. DER-CA is involved in the medical evaluation and education around the pump start. Reimbursement will be through WRHA and MB Health admin and not DER-CA.  

 

Families should not purchase pumps without first going through the program’s set process and forms with DER-CA. It will take months to get this new program running to its capacity. We will continue to maintain a list of patients interested in starting the pump. Patients and families currently on insulin pump therapy can obviously continue to access the support and education services through DER-CA.

 

New Brunswick

The New Brunswick Pediatric Insulin Pump Program (PIPP) supports New Brunswick children living with diabetes whom are medically eligible for insulin pump therapy. The program seeks to assist families to obtain fair and affordable access to a range of insulin pump devices and the basic operating supplies.  The family is responsible for a portion of the equipment and supplies based on family income.  The calculation for the family contribution considers family income, family size and the selected device.  New Brunswick children under the age of 19, who wish to use insulin pump therapy, must meet the medical criteria and complete a PIPP Approval Authority Form together with their pediatrician.  Only devices included in the Approved Vendor List are eligible for support.  The parent(s) complete and mail the Family Contribution Assessment section and the supporting documentation to the PIPP Coordinator.  This will be used to determine the family financial contribution. Once accepted, the family will receive their insulin pump device and supplies directly for the device vendor. Families will pay their family contribution for the pump device and supplies directly to the vendor.  Remaining costs are then billed to the province by the Vendor. 

For further information contact the PIPP coordinator

Toll Free: 1-855-655-5525

Phone:  506 344-3570

Fax: 506-344-3573

Email: [email protected]

 

 

Newfoundland

The Newfoundland and Labrador Pump program is open to those living in the province who have not yet turned 25 years of age. Those who are prescribed an insulin pump by their physician, have no private pump coverage and comply with guidelines provided by their diabetes care team are eligible to receive their insulin pump (one every 4 years), infusion sets, and cartridges under this provincial program.  CGM sensors, test strips, site tape, adhesives, battery caps, batteries, etc are NOT covered.

 

Diabetes care centers will help you to complete the application process. Applications are reviewed and renewed on an annual basis. 


Nova Scotia

Offers insulin pump and supply coverage for all residents with type 1 diabetes until the age of 25 based on need.  

 

Ontario

Adult coverage is now available as of September 2008

Adults with type 1 and children with type 1 are now as of September 1, 2008 eligible for insulin pump funding and the $2,400 grant for supplies.  The Ontario Disability Support Programme is funding ALL diabetic supplies for its clients and other people in the benefit unit (read spouse and dependents).  All diabetic supplies includes all insulin pump supplies.  The pump is available for people with type 1 Diabetes if they apply to ADP

Details as of January 2007: We are pleased to inform you of an initiative of the Ontario provincial government to fully fund insulin pumps and provide a grant to help pay for insulin pump supplies for children and youth with type 1 diabetes that live in the Province of Ontario.

This exciting initiative, announced by the Ministry of Health and Long –Term Care, will ensure that cost is not a barrier to the initiation of insulin pump therapy in children and youth. This program is administered by the Assistive Devices Program (ADP) and became effective December 1st, 2006. If you have purchased a pump and ongoing pump supplies between April1 and November 30, 2006 and do not have 100% third party coverage, then you may apply for the portion of the costs incurred directly by you (eg. 20% not covered by insurance).

We have identified that you/your child is presently on an insulin pump and you may be eligible for reimbursement of expenses under this program. In order to do so you must submit an application and the following items:

~Original receipts of the pump purchase and pump supplies indicating
the portion of costs incurred by you.
~If you started pump therapy prior to April 1st, 2006, you are also
eligible for reimbursement for the portion of costs related to supplies incurred by you from April 1st to November 30th. You must submit receipts of the supplies indicating portion paid.

To receive this grant for future insulin pump supplies, an application must be made by our center on your behalf. In order for us to complete this application, we must do an assessment to ensure you/your child meets the established criteria outlined by this program. To be eligible for the program, you/your child must have:
~ Completed an insulin pump education program
~Demonstrated a commitment to blood glucose monitoring before each
meal and before bedtime
~Commitment to ongoing recording of blood glucose results
~Demonstrated appropriate site rotation
~Demonstrated appropriate sick day knowledge and management
~No more than one DKA in last 6 months
~Maintained regular clinic visits (at least 3 visits in previous year)
~HbA1c less that 10

For applications and further information visit the ADP website at: http://www.health.gov.on.ca/english/providers/program/adp/adp_mn.html
or contact your diabetes center for further information.
For specific questions please contact:
Assistive Devices Program staff would be most pleased to answer questions, phone contact information is provided below:
Contact numbers for ADP by telephone:
(416) 327-8804
Toll Free 1-800-268-6021
TDD 1-800-387-5559 or local 416-327-3282


Quebec

On April 16, 2011 Quebec Health Minister Bolduc announced a reimbursement program that will cover insulin pumps for Type 1 diabetes patients aged 0 to 18 years old. To get the device, the patient and parents must pledge their compliance to the treatment protocol.

For a comprehensive look at the current program please view the work of Anna Kiff.

 

Saskatchewan

Government of Saskatchewan Budget 2007-08 (Making Life Better in Saskatchewan)
Implementing coverage for insulin pumps for people under 25 years of age (effective January 2012)

Diabetes advocates welcomed the recent Saskatchewan provincial budget announcement of a Children’s Insulin Pump Program. The new program will provide people under the age of 25 who meet eligibility requirements with one pump every five years, and coverage for insulin pump supplies as regular benefits under the Drug Plan. This commitment will benefit families
who pay approximately $6,000 per pump and an additional $300 per month in supply costs.

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