"Special Authorization Request Form - Request for Coverage of Blood Glucose Test Strips" - Newfoundland and Labrador, Canada

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SPECIAL AUTHORIZATION REQUEST FORM
The Newfoundland and Labrador Prescription Drug Program (NLPDP)
Request for Coverage of BLOOD GLUCOSE TEST STRIPS
Pharmaceutical Services
Department of Health and Community Services
Phone:
(709) 729-6507
P.O. Box 8700, Confederation Bldg.
Toll Free Line:
1-888-222-0533
St. John’s, NL A1B 4J6
Fax:
(709) 729-2851
Patient Information
Patient Name
Date of Birth
NLPDP Drug Card/MCP Number
Address
DIAGNOSIS (Please check)
 Type 1 Diabetes
 Type 2 Diabetes
 Gestational Diabetes / Pregnant with Type 2 Diabetes
Requesting
# of strips/month x
# of months
Expected Delivery Date:
 Other: Please specify
 Diet and Exercise Controlled
 Diabetic Oral Medication Only
Provide name of medication(s)
 Long Acting Insulin (Basal)
Provide name of insulin
 Short Acting Insulin (Bolus)
Provide name of insulin
EXCEPTIONAL CIRCUMSTANCES (Please check all that apply)
 Acute illness
 Significant change in routine or changes in drug dose or regimen
 Trying to become pregnant
 Poorly controlled or unstable blood glucose levels
 Increased risk of hypoglycemia.
Explain:
 Hypoglycemia poses a safety hazard at work.
Occupation:
 Exceeded the 2500 annual maximum. Requesting
# of strips per day.
Explain:
 Other - Please Explain:
EXTENUATING CIRCUMSTANCES
A request for additional strips, beyond the EXCEPTIONAL CIRCUMSTANCES, may be made in writing if there is a specific
medical need. Please attach supporting information demonstrating the need including the amount of extra strips required.
 Physician
 Pharmacist  Other Healthcare Professional
Prescriber Information / Requested By:
Prescriber Name:
License Number:
Phone Number:
Address:
Fax Number:
Signature:
Date:
SPECIAL AUTHORIZATION REQUEST FORM
The Newfoundland and Labrador Prescription Drug Program (NLPDP)
Request for Coverage of BLOOD GLUCOSE TEST STRIPS
Pharmaceutical Services
Department of Health and Community Services
Phone:
(709) 729-6507
P.O. Box 8700, Confederation Bldg.
Toll Free Line:
1-888-222-0533
St. John’s, NL A1B 4J6
Fax:
(709) 729-2851
Patient Information
Patient Name
Date of Birth
NLPDP Drug Card/MCP Number
Address
DIAGNOSIS (Please check)
 Type 1 Diabetes
 Type 2 Diabetes
 Gestational Diabetes / Pregnant with Type 2 Diabetes
Requesting
# of strips/month x
# of months
Expected Delivery Date:
 Other: Please specify
 Diet and Exercise Controlled
 Diabetic Oral Medication Only
Provide name of medication(s)
 Long Acting Insulin (Basal)
Provide name of insulin
 Short Acting Insulin (Bolus)
Provide name of insulin
EXCEPTIONAL CIRCUMSTANCES (Please check all that apply)
 Acute illness
 Significant change in routine or changes in drug dose or regimen
 Trying to become pregnant
 Poorly controlled or unstable blood glucose levels
 Increased risk of hypoglycemia.
Explain:
 Hypoglycemia poses a safety hazard at work.
Occupation:
 Exceeded the 2500 annual maximum. Requesting
# of strips per day.
Explain:
 Other - Please Explain:
EXTENUATING CIRCUMSTANCES
A request for additional strips, beyond the EXCEPTIONAL CIRCUMSTANCES, may be made in writing if there is a specific
medical need. Please attach supporting information demonstrating the need including the amount of extra strips required.
 Physician
 Pharmacist  Other Healthcare Professional
Prescriber Information / Requested By:
Prescriber Name:
License Number:
Phone Number:
Address:
Fax Number:
Signature:
Date:
Blood Glucose Test Strip Policy
Effective July 1, 2016
Special Authorization is NOT REQUIRED in the following circumstances:
-
beneficiaries managed by DIET AND EXERCISE, not receiving any diabetic oral
medication or insulin, are eligible to receive a maximum of 51 test strips per year
-
beneficiaries receiving diabetic ORAL MEDICATIONS only are eligible to receive a
maximum of 102 test strips per year
-
beneficiaries receiving LONG ACTING INSULIN (and not using short acting insulin) are
eligible to receive a maximum of 714 test strips per year
-
beneficiaries receiving SHORT ACTING INSULIN are eligible to receive a maximum of
2550 test strips per year.
Special Authorization IS REQUIRED in the following circumstances:
-
beneficiaries exceeding the annual maximum number of test strips as outlined above
-
beneficiaries being treated with diabetic oral medications and/or insulin NOT FUNDED
through NLPDP
-
beneficiaries with gestational diabetes or pregnant with Type 2 diabetes.
If Special Authorization is approved under Exceptional Circumstances:
-
beneficiaries managed by DIET AND EXERCISE, not receiving any diabetic oral
medication or insulin, will be authorized for additional 51 test strips annually; fill dates
must be at least 6 months apart
-
beneficiaries receiving diabetic ORAL MEDICATIONS only will be authorized for an
additional 51 test strips annually
-
beneficiaries receiving LONG ACTING INSULIN (and not using short acting insulin) will
be authorized for an additional 102 test strips annually.
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