What the CGM initial request is for
The form asks Pacific Blue Cross to approve coverage of a continuous glucose monitor and supplies under a member’s extended health care plan for one year. Completing it doesn’t mean approval, and the form notes that CGM coverage isn’t available under all Pacific Blue Cross plans. After a year, the member uses the CGM renewal request form.
Who completes it
The plan member completes Part 1, their own and the patient’s details, and signs Part 6, the member consent and declaration. The physician who is the primary physician managing the patient’s CGM completes Parts 2 to 5. The form marks member sections in red and physician sections in black.
Usually the patient brings the form to an appointment with Part 1 half done, or the clinic hands it over and waits for it to come back signed before faxing or mailing. In Medulla, you send Part 1 and Part 6 to the patient over a secure link before or after the visit. They complete them on the form itself, and their answers land on the same PDF you complete Parts 2 to 5 on, so Pacific Blue Cross receives one complete form.
How to fill in the physician’s part
Part 2: Physician managing the CGM
Enter your name, College ID and address, and tick your specialty. If you aren’t an endocrinologist, give the patient’s endocrinologist’s name, College ID and address. Then sign the certification that you are the primary physician managing the patient’s CGM and that the information is accurate and current.
Part 3: CGM request information
Give the brand and model number of the CGM requested.
Part 4: Patient information
Tick each criterion the patient meets. All six must be met: type 1 diabetes, insulin through an infusion pump, compliance with the current diabetes regimen, at least two visits with an endocrinologist or diabetes specialist in the past year, multiple unexplained hypoglycemic events or hypoglycemia unawareness, and an HbA1c outside the range you consider optimal. Attach the most recent HbA1c, taken within the last six months.
Part 5: Additional information
Use this space for anything the checkboxes don’t capture, such as the hypoglycemic events and their dates, or why the current HbA1c isn’t optimal.
Common reasons it’s sent back
- One of the six criteria not ticked, or not met.
- No HbA1c attached, or one older than six months.
- Endocrinologist details missing when the completing physician isn’t one.
- Part 6 not signed by the member.
- Pages stapled, which the form asks members not to do.
Submitting and who pays
The member submits the form to Pacific Blue Cross by mail to PO Box 7000, Vancouver, by drop-off at 4250 Canada Way, Burnaby, or by fax. The patient pays any fee the physician charges for the form, and it isn’t reimbursed under the plan.