Ask the Experts: annual quantity limits for blood glucose test strips?

November 27, 2018 The Tablet
Couple looking at blood glucose monitor

Q: What are the annual quantity limits for blood glucose test strips when processing through various public/private payer plans?

A: PharmaCare
PharmaCare introduced annual quantity limits for blood glucose test strips (BGTS) back in 2015. These limits are based on the type of diabetes-related medications a patient is taking in the previous 180 days and the patient is assigned to one of four categories:

  1. Managing diabetes with insulin: Annual quantity limit of 3,000 test strips
  2. Managing diabetes with anti-diabetes medications with a higher risk of causing hypoglycemia: Annual quantity limit of 400 test strips, including, but not limited to, insulin secretagogues (e.g. sulfonylureas, meglitinides)
  3. Managing diabetes with anti-diabetes medications with a lower risk of causing hypoglycemia: Annual quantity limit of 200 test strips, including, but not limited to, alpha-glucosidase inhibitors (e.g. acarbose), biguanides (e.g. metformin), dipeptidyl peptidase-4 inhibitors (DPP4I), incretin mimetics/glucagon-like peptide (GLP-1) agonists, sodium-glucose cotransporter 2 (SGLT2) inhibitors (e.g. canagliflozin), thiazolidinediones (TZDs).
  4. Managing diabetes through diet/lifestyle: Annual quantity limit of 200 test strips.

For patients in categories 2, 3 and 4, physicians may request an additional 100 test strips above the annual limit through the Special Authority process. It should be noted that:

  • These limits apply to all BGTS purchased, regardless of coverage.
  • There are two different PINs for each eligible brand of test strip to choose from when processing claims for BGTS; one used for patients who have not exceeded their annual limit, and another for patients with Special Authority coverage for additional test strips.

Most blood glucose testing strips are benefit items under Plans I, C, F and W, reimbursed at their actual acquisition cost up to the PharmaCare maximum price for the product, plus a dispensing fee. To qualify for coverage, all patients (except those covered under Plan W) must first complete blood glucose monitoring training at an accredited Diabetes Education Centre. For more information, please see section 5.16 of the PharmaCare Policy Manual or contact the help desk at (604) 682-7120 or toll-free at 
1 (800) 554-0225.

NIHB (Only for patients not covered under Plan W) 
BGTS listed in section 36:26.00 of the PharmaCare Policy Manual are limited use benefits and do not require prior approval. Similar to PharmaCare, the number of test strips covered will depend on the patient’s category. Patients are again assigned to one of four categories, with a slight difference in category 1:

  1. Managing diabetes with insulin: Quantity limit of 500 test strips per 100 days.
  2. Managing diabetes with diabetes medication with a higher risk of causing hypoglycemia: Annual quantity limit of 400 test strips.
  3. Managing diabetes with diabetes medication with a lower risk of causing hypoglycemia: Annual quantity limit of 200 test strips.
  4. Managing diabetes through diet/lifestyle: Annual quantity limit of 200 test strips.

Claims for BGTS must be submitted with a valid PIN from NIHB Drug Benefit List (note that these PINs are different than those used by PharmaCare).

Pacific Blue Cross
Unlike PharmaCare, the limit for BGTS through Pacific Blue Cross is 3,000 strips per claimant per year (maximum 100 days’ supply for each claim still applies), regardless of patient category or medication used for diabetes (insulin or oral glucose lowering medications). Claims for BGTS must be submitted with a valid PIN from the PharmaCare Diabetes Product Identification Numbers list, found on the PharmaCare website.

However, effective Jan. 1, 2019, Pacific Blue Cross will align with PharmaCare’s quantity limit based on the same four categories found under the PharmaCare section of this article.

For more information, please see section 5.12 of the Pacific Blue Cross Pharmacy Reference Guide or the help line at (604) 419-2000  or toll-free at 1 (877) 722-2583.

TELUS Health
Previously, the TELUS Health Pharmacy Manual contained a section titled “Monthly Maximums” that indicated that the maximum quantity limit for BGTS was 600 strips per 100 days. The manual has since been revised in April 2018 and this section has been removed. We’ve received confirmation from TELUS Health that the reason for removal was because system functionality is now in place to allow applicable messaging to appear as response messages visible on the adjudication screen indicating the allowable maximum. Claims for BGTS must be submitted with a valid PIN from TELUS Health’s Diabetic Pseudo-DIN List. If any questions arise, pharmacies are advised to contact the provider support centre at 1 (800) 668-1608.

Green Shield Canada
Patients with Green Shield coverage for BGTS are assigned to one of two categories:

  1. Non-insulin dependent diabetics: Annual quantity limit of 600 test strips.
  2. Insulin-dependent diabetics: Annual quantity limit of 3,000 test strips.

Note that under Green Shield, the annual limit applies starting from the date of the first paid claim and not the calendar year. For questions or further clarification, please contact the Green Shield customer service centre at 1 (888) 711-1119.

Ask the Experts is a column written by BCPhA’s Pharmacy Practice Support team. In it, they answer some of the most common questions from members. Got a question you want answered in print? Contact us.
 

This article is featured in The Tablet. The Tablet features pharmacy and industry news, profiles on B.C. pharmacists, information on research developments and new products.