Canada Life uses this request when a workplace plan member needs blood glucose test strips above the provincially indicated quantities within a 365-day period. The prescriber states the additional quantity and the medical reason, such as insulin-dependent diabetes, gestational diabetes or glycemic targets not met for three months. Approval may be time-limited, after which the member must reapply.
The plan member completes the patient information and signs the privacy consent and declaration; the prescribing physician completes the physician section with the quantity, rationale, signature and licence number.
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Request for Blood Glucose Test Strips
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When medical evidence shows the patient needs strips above the provincially indicated amounts within a 365-day period. The prescriber selects the reasons that apply, such as insulin-dependent diabetes, gestational diabetes or glycemic targets not met for three months or more, and states the additional quantity requested.
According to the form, coverage may be granted for a set period of time, after which the member must re-apply for continued coverage. Assessment can be delayed if the form is incomplete, so every question should be answered and all pages returned.
The plan member fills in the patient information and signs the consent; the prescribing physician completes the physician section with specialty, contact details, the additional quantity, the medical rationale, signature and licence number. Any completion cost is the member's or patient's responsibility.