Not covered for CGM


#1

I live in Canada and am on disability. Pharmacare said they won’t cover a glucose monitor (nor a pump, which I’m not comfortable with the idea with anyway). Is there any way around this? I’m almost sure my endo won’t help me at all with it because he insists that I shouldn’t have to check my bg more than 10 times a day. I check more than 20 and my fingers are kind of in bad shape. Also, its really expensive and consuming. My life would be so much more of a life if I could get a monitor. What should I do?


#2

I think in order to speak to that, first we’d need to know why you are checking more than 20 times a day?

Are y
Are you experiencing frequent hypo or hyperglycemic episodes?
Have you lost hypo awareness?
Are you currently working out a basal/bolus dosing schedule and figuring out your insulin-to-carb ratio?
Are you checking frequently due to fear of having a low while driving and/or engaging in things such as operating machinery?

Checking 20 times a day is somewhat excessive unless there’s some sort of extenuating circumstance.


#3

We should not judge why a person checks 20 times a day! I do that…I can’t wear a CGM, am hypo unaware, and some days have a lot of running around to do and won’t start my car without a bg check. What you think is excessive is what my doc and insurance think is the best way to make sure I don’t go running around with a hypo on the road or in my work and life. Sheesh!

If your endo won’t support your checking then you might need to find a new one, Maria32. Even if your endo gets on board, getting Pharmacare to cover will be your bigger battle. Good luck.


#4

Thank you Karen57


#5

You are welcome :sunny:


#6

Shame on Pharmacare for intervening and making medical decisions about your care. My recommendation is that you learn to “play the game” and play it well. We all deal with insurance and bureaucracy. I suspect you have run into the standard no, no, no. Here are the rules that I found from Pharmacare. It seems like by default you get 8 strips a day. If you have not already done so, you should have your endo help you through the steps to request more strips based on your disability and hypo unawareness. If that fails I presume if you get your endo to help with the next level of appeal with a separate letter of medical necessity.

The standard approach of organizations like Pharmacare which have as a mission to control costs is to say no. Your job is to nicely and insistently not accept no. The same goes for a CGM.

In the meantime you could also consider some inexpensive meter strip combinations. Maybe you can get the Relion meter and strips at Walmart or perhaps order something like the On Call from Amazon.


#7

I am not judging. There is a difference between “judging” and trying to find an extenuating circumstance, such as those I questioned/suggested, that might make the 20-checks and/or a CGM be deemed medically necessary. If I were hypo unaware, but drove frequently and made multiple trips in a day - yes, I’d check every single time I got in the car.

And I’d definitely give my doctor the stink-eye for telling me that it wasn’t necessary, which is what Maria32’s doctor is currently telling her. But I also don’t know what information Maria32’s doctor has, as to why she’s checking 20 times a day, thus my inquiries.

I’m sorry if my reasoning for asking for more information wasn’t more clear. Maria32 asked “Is there any way around this?” - Generally a “yes” to the types of questions I asked, especially hypo-unawareness, are the beginning of how to get something deemed medically necessary IF one’s doctor is cooperative.


#8

Thank you for your support. I have seen 2 endo’s. Both were super rude and flippant…Maybe it would eventually pay off for me to look for another endo. Those two that I saw were the only two in my area, but if I could find a helpful endo it would totally be worth the trip downtown…I don’t know where the pharmacists get this idea that we only need 8 strips a day. They used to tell me that all the time but have given up. lol
If I was to only check 8 or 10 times a day, I think something would have happened to me by now.
Thank you for the helpful info. I’m going to push for this more and see what I can do.


#9

I have felt the need to answer to many people, many times (including pharmacists, family, clinicians and endo’s) for why I check so much. I’m not going go through this explaining again. I check because I feel a need to check. I have to buy every 2nd box of strips because so-called professionals have decided how many strips a day I need. How other people stick to using so little strips a day is beyond me, especially considering all the things that affect blood sugar----hormones, getting sick, weather, exercise…etc
And then the fact that in almost every box of strips, there are some defective ones that don’t work.
I don’t poke myself for fun, or because i enjoy running out of $ way before my next check.

No, I don’t drive. But that doesn’t mean that I would like to have a hypo that I didn’t see coming, or that I would like my bg running high for too long or too many times, so that some day i can have complications.

Don’t mean to sound snippy, but so far, I do find it necessary to use the amount of strips that i do. And I would choose sore fingers and less money any time over a coma or some other disaster, which all these “professionals” telling me how many strips I need, can never make up for.


#10

You don’t sound snippy. You sound frustrated. I’m pretty sure we’ve all been there at one time or another with one medication or supply or another.

We all have to do what we need to in order to feel safe and ensure our best health. Unfortunately, our doctors and insurance companies often don’t agree with us as to what is necessary. There’s a lot of hoops to jump through to get what we need sometimes, and often it’s just easier to pay out of pocket than fight the system. They make it hard in hopes that we’ll go away, and many times it works. It’s like they have no sense about the fact that spending a little money now will save them lots later in not having to pay for treatment of complications. Test strips are way cheaper than dialysis!

You’ve already tried another doctor. I don’t know if a third would help or not. I know people always rail against doctors getting kickbacks or whatever from various drug companies and whatnot, but I wonder if that is something you could use in your favor in the case of a CGM? Perhaps calling the CGM company of your choice, be it Dexcom or another company, and asking for help in finding a doctor who will declare it as medically necessary?


#11

You might do a bit of searching here on strips and cost of supplies. Canada is very different from the US, but there are a number of TUDers who buy strips out-of-pocket for prices in the range of what some of us pay in co-pays. I know @sam19 has posted on this several times and he finds the quality very acceptable. I believe he gets his at Walmart. Not sure what the Canadian equivalent would be but if there’s something equivalent it might be a way to supplement the ones insurance is willing to cover without driving yourself nuts arguing the point with them or taking out a second mortgage. :slight_smile:


#12

Thank you everyone for your very helpful tips. This means a lot to me and I’m definitely going to look into these things. Just reading these posts I’m starting to feel more hopeful :sunny:


#13

Not Walmart… Walmarts cheap strips are the relion prime, which the user reviews I’ve read have been kinda ho-hum and I’ve never seen professional reviews on.

but truetest strips (which I purchase on Amazon) I can tell you from many thousands of strips of experience are excellent. I can also tell you that consumer reports rated them higher than any brand name strip except freestyle in both accuracy and repeatability… The rest of the pack was way, way behind freestyle and truetest.

I believe freestyle and truetest are indisputably the best strips on the market by a country mile. However my insurance covers neither, and I certainly don’t want to pay cash price for freestyle… But truetest run $45 for 300 on Amazon. I have exactly zero interest in using anything else at this point. I can’t recommend them enough. Only downside is if you like all the high tech gadgetry, downloading your meter to your computer, software integration and colorful printouts etc they may not be for you-- i personally am not interested in any of that stuff though.

I like them so much that I chose to pay cash for them instead of getting for zero cost the strips my insurance covers… And I’m a very frugal person-- so that says something…


#14

I could be wrong (I haven’t checked in a while), but it seems like these cheap meters and strips are not available in Canada and Amazon.com will not ship to Canada (probably because of the prescription needed, or something like that). Unfortunately, Pharmacare is not up to date with their coverage—in part because they base their coverage on medical literature (which doesn’t show that basal/bolus improves overall control, so they don’t even cover the full cost of insulin analogues!), and also because they base their decisions on what most people need (before making the test strip limit decision, they collected data that showed only 169 people in the province test more than eleven times per day).

As far as I know, there is no way to appeal Pharmacare the way there is with insurance companies, unless there is a specific option like having your endocrinologist write a letter stating that you need more than eight tests a day (which you should do—everyone I know who has done so has been approved for more strips without question). Your best bet for CGM coverage is to advocate to MLAs and Pharmacare that we need this coverage, but unfortunately that type of advocacy can take years. There are some Facebook groups dedicated to this type of advocacy in BC that I can pass on to you if you’d like. I’m a member of one advocating for insulin pump coverage for adults (currently the cutoff age is 25), but the group also has posts about other topics such as CGM coverage.


#15

Sure, the more info the better! I will call Walmart too and find out what they have.
So far I have tried 2 different endo’s who were both very rude and uncooperative, but I will look for a 3rd one.
I think this time I will try to find reviews first. Thank you Jen!


#16

Are you in the Metro Vancouver area?


#17

yes, around there


#18

Maria - I’m in Calgary (AB), have been type 1 for 52 years. I’ve been hypo unaware for nearly 18 years. Much is the same in our province with regard to healthcare paying for diabetic supplies & meds.

The Alberta government finally offered to pay for a pump program several years ago, which covers everything except insulin. Once on the pump program they’ll also pay for 700 test strips per month. For those not in Canada, meters are free, but strips cost about $70 per box of 100.
Note the province pump program does NOT cover CGM, that cost me roughly $4,000/yr out of pocket
Jim


#19

I had no idea that pump coverage was so restricted in Canada, or more accurately that it’s so uneven, with some provinces offering it to adults, some restricting to age 25 (or 26), some cutting you off after age 18. Must be really fun for people dx’d as children, who have grown up being totally acclimated to dealing with it in this more controllable way and are then told “Now you’re an adult, you gotta cowboy up and do your own shots.” We certainly have problems with our system in the US, price gouging among insulin manufacturers being one, but this seems really harsh. What’s the rationale?


#20

Thank you, I probably need to look into it and see if anything has changed since I last investigated.
I think pharmacare told me (if I remember right) that if I get permission from my endo and get him to sign something, that I could maybe be covered for a pump…To tell you the truth, the thought of switching to a pump is some how a scarey thought to me. I looked up CGM’s online maybe a year ago and I read somewhere that they were around $7,000 a year. I’m going to try looking it up again. $4,000 sounds better :slight_smile: