Coverage for Dexcom CGM
To be eligible for coverage for Dexcom G6 under BC PharmaCare, patients must:
- Be registered with Fair Pharmacare, Plan C, Plan F or Plan W; and
- Meet the BC PharmaCare coverage criteria as specified in the BC PharmaCare Special Authority form.
Most private health plans require patients (members) to enroll and submit claims to PharmaCare first.
- If they are approved for PharmaCare coverage, the pharmacist will submit claims to PharmaCare first. Coverage is coordinated at the point of sale, with billing to PharmaCare, the patient, and their private insurance depending on where the patient is with their accumulated deductible and coinsurance maximum. Standard copays will apply as per the persons policy.
- If the patient is not approved for PharmaCare, the pharmacist will submit to their private insurer if the patient has a private plan and collect the copayment. Coverage varies by plan and policy.
- Some private plans will not be initially setup to automatically pay claims for Dexcom at pharmacy. Patients with these plans, who are approved for coverage, will need to pay the pharmacy directly for their deductible or copayment amounts, and then submit their receipts to their insurer for reimbursement.
- Patients with private insurance should check with their insurer to confirm if their plan is setup to reimburse Dexcom at pharmacy directly, and what (if any) documentation is required for them to obtain coverage approval for pharmacy claims.
If additional support is needed, please have the patient contact Dexcom at 1-844-832-1810.
Once the Special Authority application has been submitted, approval generally takes a few days but it may take up to 3-4 weeks.
- Patients may call their prescriber or their pharmacist to confirm the request has been approved. Patients may also call PharmaCare at 1-800-663-7100 (toll-free) or 604-683-7151 (from the Lower Mainland).
- When presenting their prescription at the pharmacy, the pharmacist will submit their coverage claim to BC PharmaCare and, when needed, coordinate coverage between BC PharmaCare and private insurance.
- Please be aware that BC PharmaCare will not retroactively reimburse patients for benefits purchased before approval of a Special Authority request.
Once approved, the patient’s initial request is valid for 1 year. After that time, coverage may be renewed for 5 years if the patient continues to require multiple daily injections of insulini or insulin pump therapy as part of intensive insulin therapy and will benefit from continued use of a continuous glucose monitor.
i. Multiple daily injections of insulin is defined as one (or more) injection(s) of basal insulin and three (or more) injections of bolus insulin, with a minimum of at least of four total insulin injections per day.
Residents of British Columbia, 2 years of age and older with diabetes mellitus (DM) and meet the following criteria:
- Requires multiple daily injections of insulini or insulin pump therapy as part of intensive insulin therapy, and
- The patient/family/caregiver agrees to comprehensive and age-appropriate diabetes education by an interdisciplinary diabetes healthcare team and commits to regular follow-up, and
- The patient has one of the following:
- Hypoglycemia unawarenessii, or
- Frequent and unpredictable hypoglycemic episodesiii, or
- Unpredictable swings in blood glucoseiv, or
- At least one functional restriction that inhibits the use of blood glucose test strips (BGTS) (e.g., dexterity, mobility, dermatological problems), or
- An occupation where hypoglycemia presents a significant safety risk (e.g., pilots, air traffic controllers, commercial drivers).
i. Multiple daily injections of insulin is defined as 1 (or more) injection(s) of basal insulin and three (or more) injections of bolus insulin, with a minimum of at least of 4 total insulin injections per day.
ii. Hypoglycemia unawareness is defined as the inability of a patient to recognize or communicate early symptoms of hypoglycemia resulting in the inability to take corrective action to prevent severe hypoglycemic episodes.
iii. Frequent hypoglycemic episodes are defined as greater than 3 episodes per week. Unpredictable hypoglycemic episodes are defined as those that are not associated with predictable causes (e.g., physical activity, reduced food intake, acute illness, medication dosing errors).
iv. Unpredictable swings in blood glucose is defined as variability in blood glucose levels of less than 4 mmol/L and/or greater than 10 mmol/L throughout the day that are not associated with a predictable cause (e.g., physical activity, food intake, acute illness, medication dosing errors.
For a complete description of coverage criteria, please visit: https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/pharmacare/prescribers/special-authority/special-authority-request-forms-drugs-medical-devices-and-supplies
All Patients in BC are encouraged to first register for BC PharmaCare, even if they have private insurance coverage.
- To be eligible for coverage for Dexcom G6 under BC PharmaCare, patients must be registered with Fair PharmaCare, Plan C, Plan F or Plan W;
- Patients should then have confirmation from their primary care provider or endocrinologist that they meet the provincial clinical requirements; and
- Patients should have their primary care provider or endocrinologist submit a BC PharmaCare Special Authority request on their behalf.
- Once their request has been approved, patients should go to their local pharmacy to obtain their Dexcom products.