Diabetes patients in B.C. face unreasonable challenges getting vital drug through PharmaCare, doctors say

This story is part of Situation Critical, a series from CBC British Columbia reporting on the barriers people in this province face in accessing timely and appropriate health care.

B.C. doctors who treat diabetes say they've been forced to jump through hoops to get coverage for potentially life-saving drugs, including making patients try cheaper but more dangerous alternatives first.

Dr. Ali Zentner, a Vancouver specialist in internal medicine and obesity, said game-changing new drugs and devices for diabetes patients have appeared in recent years.

That includes pharmaceuticals like Ozempic for people with Type 2 diabetes, which also helps with weight loss and reduces the chance of heart attack or stroke and continuous glucose monitoring, which tracks glucose levels every few minutes.

But these options are expensive, and Zentner said she's been asked to go to increasingly unreasonable lengths to prove her patients should have coverage under PharmaCare, the public program that covers the cost of some drugs.

"I could have a patient where there's a medication that, according to the Canadian diabetes guidelines, American diabetes guidelines, European diabetes guidelines, would be an ideal either first- or second-line therapy for this patient," Zentner said.

"But according to PharmaCare, they have to have failed two other agents before I can even attempt to get coverage for this patient."

The issue is that options like Ozempic and continuous glucose monitoring are only available under what's known as special authority.

The designation is given to certain drugs that aren't generally covered by PharmaCare. Coverage is only provided to patients under certain circumstances when a request is made by their doctor, and in cases like this, it's only granted when cheaper drugs have failed.

"It should piss you off and frighten you that my clinical decisions are actually not made on what's best for you and what's healthiest and safest for your long-term care but actually what's cheapest for this government," Zentner said.

Older alternatives have serious side effects

Dr. Tom Elliott, the medical director for B.C. Diabetes, said he's been dealing with the same problem. Special authority generally means he has to prove his patients have tried a class of drugs known as sulfonylureas first. 

"I don't prescribe these drugs ever because they're dangerous," he said, explaining that they can cause a person's blood sugar levels to dip so low that they pass out, have a seizure or even die.

Elliott was so concerned about the potential side-effects, he says, that he asked his patients to fill a prescription so there would be a paper trail in the provincial database, but then told them not to take the drugs.

The practice resulted in a complaint against him to the College of Physicians and Surgeons, he said. 

Even then, Elliott says some of his patients have been "serially denied" coverage, with constant requests for more information from PharmaCare or outright denied coverage.

That's a familiar situation for January Zamora, one of Zentner's patients. It took a year for her to get approval for a special authority to cover Ozempic.

"She had to advocate for me and jump through hoops," Zamora said of Zentner.

Zamora said she's seen a "huge difference" compared to the insulin she was using before.

"I gained weight. I had high blood sugars — I definitely was not active, so I was very tired," she said. "With Ozempic … it gave me some weight loss. It's given me a little bit more energy." 

Elliott said he has spoken directly with Health Minister Adrian Dix about his concerns — Dix has Type 1 diabetes and just happens to be one of his patients.

CBC requested an interview with a health ministry representative, but instead received a written statement that did not address the doctors' concerns about the special authority process for diabetes treatments.

In the meantime, Elliott has also written to the ministry to ask for change, and it looks like it's not out of the question.

In an email on Friday, Assistant Deputy Health Minister Mitch Moneo acknowledged Elliott's concerns and said he appreciated the offer to help revise special authority guidelines.

"When we are able to re‑examine our SA [special authority] criteria for the Type 2 diabetes drugs, hopefully in the near future, we will be in contact with you to further discuss your recommendations," Moneo wrote.

However, no timeline has been provided for that process.