Prescribers use this two-page Special Authority request to get BC PharmaCare coverage of a Dexcom G6 or G7 or a FreeStyle Libre 2 or 3 Plus glucose monitoring system. Initial approval runs three years and needs intensive insulin therapy, a commitment to diabetes education and a qualifying reason such as hypoglycemia unawareness; renewals run five years.
The prescriber completes sections 1 to 3 for initial coverage, or sections 1, 2 and 4 for renewal, and signs to confirm they discussed the release of information with the patient.
Download the current version from the source each time; forms change without notice.
Glucose Monitoring Systems (Special Authority request)
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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Initial criteria need diabetes in an eligible age group, insulin pump therapy or multiple daily injections, agreement to diabetes education and regular follow-up, and at least one of: hypoglycemia unawareness, frequent or unpredictable hypoglycemia, unpredictable glucose swings, a functional restriction on test strip use, or a job where hypoglycemia is a safety risk.
Initial coverage under section 3 lasts three years. Renewal under section 4 lasts five years and requires the same insulin therapy criteria plus the prescriber's confirmation that the patient will benefit from continued use of the glucose monitoring system.
PharmaCare returns forms with missing information for completion, and cannot send a response if no prescriber fax number or mailing address is given. The form marks the prescriber's fax number as critical for a timely response and the patient's Personal Health Number as critical for processing, and the signature is mandatory.