To help our members reduce their out-of-pocket costs and better manage their diabetes, we have implemented new functionality that will allow you to bill us directly for the Dexcom G6 and the Freestyle Libre continuous glucose monitoring devices. The new functionality applies to all Pacific Blue Cross plans where it is an included benefit.

How does it work?

Pacific Blue Cross can read BC PharmaCare approvals in real time at point of sale with the claim and will automatically adjudicate claims for Dexcom G6 under the plan if a BC PharmaCare approval is in place. Note that plan eligibility and reimbursement rules still apply.

How do I process the claim electronically?

Electronic claiming of additional medical supplies and equipment is limited to First Nations Health Authority (FNHA) clients under Group ID 40000. Electronic submissions for additional medical supplies and equipment for other Pacific Blue Cross members is not yet available. For these members, you will have to submit the claim manually for consideration under their plan.

How do I submit claims for medical supplies and equipment?

Charges should be included in the Drug Cost/Product Value and Cost Upcharge fields. Claims with values in the Compounding Charge or Special Services Fee(s) fields will be rejected, as these fees are not eligible for medical supplies and equipment.  While Professional Fees are not eligible for most medical supplies and equipment, they can be submitted for Dexcom G6 and Freestyle Libre devices.

What does the response code RW Special Authorization (SA) Required mean?

If a claim for a Dexcom G6 Sensor or Reader rejects with this response code, the item requires BC PharmaCare Special Authority approval before being considered under the plan.

What does the response code RD Eligible for Prior Approval mean?

If a claim rejects with this response code, the item requires pre-determination before being considered under the plan. Once the pre-determination has been submitted, it will either be approved or rejected by Pacific Blue Cross. If the pre-determination has been approved, you will then be able to electronically submit a claim for that item for the member. For pre-determination, please refer to the Flash Glucose Monitoring Request Form..

As of March 31, 2022, the Office of Controlled Substances, Health Canada has listed tramadol and products containing tramadol as a controlled substance subject to the Controlled Drugs and Substances Act and Narcotic and Control Regulations. This is to strengthen Health Canada’s oversight of legitimate activities with this medication and facilitate detection and prevention of diversion.

To align with other opioids, and to allow for regular monitoring, medication adherence, and to

address safety concerns, tramadol and products containing tramadol will be limited to a 35-day

supply under Pacific Blue Cross drug plans and this has been in effect since March 31, 2022. If a physician writes a prescription for longer than 35 days, you may still dispense 35 days at a time without having to consult the physician.

If you are claiming above limits for First Nations Health Authority (FNHA) clients, please make sure to submit a new pre-determination via fax to 604-677-0277. Be sure to fill out the form completely as we will have to reject incomplete forms. If your form is rejected, you will be able to resubmit for the claim.

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