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5.17 Insulin Pumps

Last updated on October 22, 2024

General Policy Description

PharmaCare covers insulin pumps to ensure that cost is not a barrier to the use of an insulin pump for patients with diabetes requiring the use of regular or rapid-acting insulin.

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Policy details

Patient and plan eligibility

Insulin pump coverage is available to patients who:

  • Have type 1 diabetes or another form of diabetes requiring the use of regular or rapid-acting insulin, and
  • Are covered under Fair PharmaCare, Plan C (Income Assistance), Plan F (Children in the At Home Program), Plan W (First Nations Health Benefits), or Plan B (Permanent Residents of Licensed Long-term Care Facilities), and
  • Have been confirmed as meeting the medical criteria for coverage by their diabetes physician, and
  • Have received Special Authority (SA) approval for coverage

Patients should register for Fair PharmaCare before applying for insulin pump coverage. This ensures the patient knows what their Fair PharmaCare deductible is in advance. Eligible prescription and medical device/supply costs already incurred during the year would count towards their deductible before their insulin pump purchase.

Coverage

PharmaCare coverage is limited to one insulin pump every five years (or after four years if the current pump was previously covered by an organization other than PharmaCare, such as a private insurer).

Only the makes and models of insulin pumps approved by PharmaCare are eligible for PharmaCare coverage, and only when the insulin pump is purchased from an approved vendor, as identified for the patient and their endocrinologist in their SA approval confirmation letter.

PharmaCare covers a maximum price for each insulin pump make and model, with no dispensing fee.

The Omnipod Insulin Management System personal diabetes manager is available at no cost regardless of the patient’s PharmaCare plan. The YpsoPump is available at no cost regardless of PharmaCare plan with the purchase of a Ypsomed starter kit, which is supplied at $800. The MiniMed Insulin Pump System is supplied at $6,600.

Coverage of the Ypsomed starter kit and the MiniMed Insulin Pump system is subject to the rules of the patient’s PharmaCare plan. Coverage is as follows:

  • If the patient is covered under Plan B (Long-term Care), Plan C (Income Assistance), Plan F (Children in the At Home Program), or Plan W (First Nations Health Benefits), PharmaCare covers 100% of the costs
  • If the patient is covered under Fair PharmaCare, the cost is subject to the patient’s deductible and family maximum. PharmaCare covers 70% of the costs once the patient has met their deductible. PharmaCare covers 100% of the costs once the patient has met their family maximum

Important: Patients who are not covered by a PharmaCare plan that pays 100% should register for Fair PharmaCare before purchasing an insulin pump to ensure they receive maximum coverage.

Coverage requirements

PharmaCare coverage of insulin pumps requires prior SA approval by PharmaCare. Approval is provided on a case-by-case basis.

SA approval for insulin pump coverage cannot be provided retroactively.

SA approval for the purchase of an insulin pump may be requested once every five years on behalf of an eligible patient. SA requests must be submitted by the referring specialist physician or endocrinologist.

Refer to Insulin Pump Special Authority for the medical criteria for coverage, SA request form, and instructions about how to secure coverage.

PharmaCare sends a letter confirming or denying coverage to the referring specialist physician or endocrinologist. The physician must provide a copy of the approval letter to the patient.

The patient must provide a copy of the SA approval letter to the insulin pump vendor prior to or at the time of purchase.

Insulin pump claims for patients who do not have PharmaCare SA approval will not be paid by PharmaCare.

Patients with existing insulin pumps not covered by PharmaCare

Patients with an existing insulin pump that was not covered by PharmaCare may be eligible for PharmaCare coverage if:

  • They meet the patient and plan eligibility criteria,
  • They meet the medical criteria for a subsequent insulin pump, and
  • Their current pump is four or more years old, and
  • The manufacturer's warranty for their current pump has expired

The patient’s specialist physician or endocrinologist must submit a General Special Authority request (PDF, 656KB) to PharmaCare requesting coverage.

The patient must contact their insulin pump manufacturer for a letter confirming the warranty expiry date. The physician must include this proof of warranty expiry with the SA request.

Reimbursement

Insulin pumps are reimbursed at the retail price up to the PharmaCare maximum allowable cost for the pump, with no dispensing fee.

Insulin pump repairs and replacement

PharmaCare does not cover insulin pump repairs. Manufacturers warranty their pumps for the five-year term.

PharmaCare does not cover insulin pump replacement prior to the end of the five-year period since coverage for a patient’s last pump was issued.

Insulin pump repairs and/or replacement of broken pumps are subject to the terms of the manufacturer’s warranty during the warranty period. The patient should refer all enquiries about pump repair and replacement to the vendor from which the pump was purchased.

Lost or stolen insulin pumps

Replacement costs for stolen or lost insulin pumps are not covered by PharmaCare.

Information for insulin pump vendors

A copy of the PharmaCare letter confirming SA approval for insulin pump coverage must be obtained from the purchaser and maintained on file. This letter will identify the model of pump that the patient has coverage for.

Insulin pump claims for patients who do not have PharmaCare SA approval for insulin pump coverage will not be paid by PharmaCare.

Insulin pump vendors must use the correct Product Identification Number (PIN) for the insulin pump that the patient has been approved for, as identified in the SA confirmation letter.

Information on connection to PharmaNet and online claims payment processes, as well as the processing of manual, paper based PharmaCare claims, is in the PharmaCare Claims for Insulin Pump Vendors Quick Guide (PDF, 1.2MB).

Questions and answers

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

Speak to your endocrinologist or 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. Vendors may allow you to return the pump for a refund within 90 days of purchase. In this case, the vendor will reverse the PharmaCare claim and refund any portion of the cost you paid.

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 endocrinologist or specialist physician, who will include the letter with a new SA request to PharmaCare.

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