Insulin Pumps - Special Authority Criteria

Instructions

  • Requests must be completed by an endocrinologist or a specialist physician with experience in managing pumps in children and adolescents.
  • For patients who have never used an insulin pump before, the physician should complete the form for initial coverage.
  • For patients who have already been using an insulin pump, the physician should complete the form for subsequent coverage.
  • All requests must include a HLTH 5377—Patient/Family Agreement for an Insulin Pump form signed by the patient or their parent or guardian.
  • Coverage is for one insulin pump in a five year period.
Note: If patient's current pump was not funded by PharmaCare, coverage of a subsequent pump will be considered if the pump is more than four years old and the manufacturer warranty has expired.

Product
insulin pump (continuous subcutaneous insulin infusion)

Criteria - Initial Pump Approval Period
Patient is 18 years of age or younger
PLUS—Diagnosis of Type 1 diabetes or other form of diabetes requiring insulin
PLUS—Patient/family is checking blood glucose at least 4 times daily and recording results.
PLUS—Patient and/or family agrees to age-appropriate ongoing diabetes education
PLUS—
Patient has frequent hypoglycemic episodes
OR
Patient has frequent diabetic ketoacidosis episodes
OR
Patient has unpredictable swings in blood glucose
Not applicable.
Criteria - Subsequent Pump  
Patient is 18 years of age or younger
PLUS—Diagnosis of Type 1 diabetes or other form of diabetes requiring insulin
PLUS—Patient and/or family agrees to age-appropriate ongoing diabetes education
PLUS—A1C is 9.0% or less on two occasions within 6 months prior to request
PLUS—Patient has had no more than one diabetic ketoacidosis episode in the past year
 Not applicable.

Practitioner Exemptions

  • No practitioner exemptions

Forms