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Utilization patterns and reimbursement options for diabetes test strips in British Columbia Law, Michael R.; Kratzer, Jillian; Cheng, Lucy; Donovan, Stephanie Jun 30, 2014

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Utilization Patterns and  Reimbursement Options for Diabetes Test Strips in British ColumbiaJune 2014Michael R. Law, PhDJillian Kratzer, MScLucy Cheng, MScStephanie Donovan, MPPUtilization Patterns and Reimbursement Options for Diabetes Test Strips in British Columbia was produced by:Centre for Health Services and Policy ResearchUniversity of British Columbia201–2206 East MallVancouver, BC V6T 1Z3Phone: 604-822-4969Email: enquire@chspr.ubc.ca1ContentsUBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CH3	 List	of	Figures3	 List	of	Tables4	 About	CHSPR4	 Acknowledgments5	 List	of	Acronyms6	 Introduction6	 	 	 Diabetes	and	Glycemic	Control6	 	 	 Self-Monitoring	Blood	Glucose:	Rethinking	Current	Practice6	 	 	 Public	Coverage	for	Test	Strips	in	BC7	 	 	 Cost	Trends	for	Public	Drug	Programs7	 	 	 Research	Objectives8	 Background8	 	 	 Overview	of	Current	Evidence9	 	 	 Optimal	Therapy	Recommendations	and	Clinical	Practice	Guidelines10	 	 	 SMBG:	The	Controversy12	 Jurisdictional	Overview:	Existing	Public	Coverage	Policies12	 	 	 Canadian	Patient	Eligibility	Criteria	and	Benefits13	 	 	 Benefit	Prices	and	Dispensing	Fees14	 	 	 International	Context14	 	 	 	 	 Patient	Eligibility	Criteria	and	Benefits14	 	 	 	 	 Benefit	Prices	and	Dispensing	Fees17	 Data	Sources	and	Methodology17	 	 	 Study	Design17	 	 	 Data	Sources17	 	 	 Study	Population	and	Diabetes	Therapy	Groups18	 	 	 Test	Strip	Utilization	and	Cost18	 	 	 Reimbursement	Restriction	Scenario18	 	 	 International	Price	Comparisons19	 Results19	 	 	 Test	Strip	Utilization	and	Cost19	 	 	 	 	 SMBG	Use	by	Diabetes	Therapy	Groups21	 	 	 	 	 SMBG	Cost	by	Diabetes	Therapy	Groups21	 	 	 Reimbursement	Restriction	Scenario23	 	 	 	 	 Potential	Impacts	of	Quantity	Limits24	 	 	 International	Price	Comparisons    U T I L I Z A T I O N  PA T T E R N S  A N D  R E I M B U R S E M E N T  O P T I O N S  F O R  D I A B E T E S  T E S T  S T R I P S  I N  B C225	 Discussion25	 	 	 Policy	Implications25	 	 	 Challenges	and	Opportunities25	 	 	 Limitations26	 	 	 Conclusions27	 References30	 Appendix	1:	Oral	Anti-Diabetic	Medications31	 Appendix	2:	Test	Strip	Brand	NamesUBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CH3List of FiguresList of Tables19	 Figure	1.	Annual	number	and	total	cost	of	blood	glucose	test	strips	dispensed	to	patients	aged	18	years	and	older	covered	by	the	PharmaCare	program	in	BC,	2004	to	201220	 Figure	2.	Proportion	of	patients	aged	18	and	older	with	diabetes	using	blood	glucose	test	strips,	by	diabetes	therapy	group,	in	BC,	2004	to	2012	20	 Figure	3.	Annual	PharmaCare	cost	of	blood	glucose	test	strips	dispensed	to	patients	aged	18	and	older	with	diabetes,	by	diabetes	therapy	group,	in	BC,	2004	to	201223	 Figure	4.	Costs	of	blood	glucose	test	strips	associated	with	the	Ontario	scenario	related	to	testing	frequency,	in	patients	aged	18	years	and	older,	in	BC,	calendar	year	201223	 Figure	5.	Projected	total	costs	of	blood	glucose	test	strips	associated	with	the	Ontario	scenario	related	to	testing	frequency,	in	patients	aged	18	years	and	older,	in	BC,	calendar	years	2013	to	20179	 Table	1.	Summary	of	CERC	optimal	therapy	recommendations	10	 Table	2.	Summary	of	the	CDA’s	2013	Clinical	Practice	Guidelines12	 Table	3.	Summary	of	patient	eligibility	criteria	and	yearly	benefits13	 Table	4.	Summary	of	provincial	test	strip	reimbursement15	 Table	5.	Summary	of	patient	eligibility	criteria	and	yearly	benefits16	 Table	6.	Summary	of	international	test	strip	reimbursement17	 Table	7.	Diabetes	therapy	groups18	 Table	8.	Test	strip	quantity	restriction	scenario	by	diabetes	therapy	group21	 Table	9.	Blood	glucose	test	strip	utilization	and	costs,	for	patients	aged	18	years	and	older,	for	the	BC	PharmaCare	program,	calendar	year	201221	 Table	10.	Number	of	patients	impacted	by	the	Ontario	scenario,	based	on	diabetes	therapy	group,	in	201222	 Table	11.	Reduction	in	utilization	and	cost	associated	with	the	Ontario	policy	scenario	related	to	testing	frequency,	for	patients	aged	18	years	and	older,	in	BC,	calendar	year	201222	 Table	12.	Estimates	on	test	strip	limits	for	insulin	users,	for	patients	aged	18	years	and	older,	in	BC,	in	201224	 Table	13.	Comparison	of	international	prices	for	top	ten	test	strip	brands	in	BC,	by	utilization,	January	2014	prices30	 Table	14.	Pharmacotherapy	treatments	by	risk	of	hypoglycemia31	 Table	15.	Test	strip	products	eligible	for	coverageU T I L I Z A T I O N  PA T T E R N S  A N D  R E I M B U R S E M E N T  O P T I O N S  F O R  D I A B E T E S  T E S T  S T R I P S  I N  B C4AcknowledgmentsAbout CHSPRThe Centre for Health Services and Policy Research (CHSPR) is an independent research centre based in the School of Population and Public Health of the University of British Columbia. Our mission is to stimulate scientific enquiry into health system performance, equity and sustainability. Our faculty are among Canada’s leading experts in primary health care, health care funding, variations in health services utilization, health human resources, and pharmaceutical policy. We promote interdisciplinarity in our research, training, and knowledge translation activities because contemporary problems in health care systems transcend traditional academic boundaries. We are active participants in various policy-making forums and are regularly called upon to provide policy advice in British Columbia, Canada, and abroad. We receive core funding from University of British Columbia. Our research is primarily  funded through competitive, peer-reviewed grants obtained from Canadian and international funding agencies.For more information about CHSPR, please visit www.chspr.ubc.ca.This project was made possible by a research grant from the Canadian Institutes for Health Infor-mation (CIHI). Michael Law received salary support through a New Investigator Award from the Canadian Institutes of Health Research and a Scholar Award from the Michael Smith Foundation for Health Research.UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CH5List of AcronymsA1C  Glycated haemoglobin, also known as HbA1cBGTS  Blood glucose test stripsCADTH Canadian Agency for Drugs and Technologies in HealthCCDSS  Canadian Chronic Disease Surveillance SystemCDA  Canadian Diabetes AssociationCERC  COMPUS Expert Review CommitteeCOMPUS Canadian Optimal Medication Prescribing and Utilization ServiceDUO  Drug Use OptimizationEQIP  Education for Quality Improvement in Patient CareGPAC  Guidelines and Protocols Advisory CommitteeOTC  Over-the-counterPHAC  Public Health Agency of CanadaPHARMAC Pharmaceutical management Agency of New ZealandPSD  Pharmaceutical Services DivisionQALY  Quality-adjusted life-yearSMBG  Self-monitoring blood glucoseT1D  Type 1 diabetesT2D  Type 2 diabetesU T I L I Z A T I O N  PA T T E R N S  A N D  R E I M B U R S E M E N T  O P T I O N S  F O R  D I A B E T E S  T E S T  S T R I P S  I N  B C6IntroductionDiabetes and Glycemic ControlDiabetes is a complex, chronic illness affecting approximately 400,000 British Columbians—roughly 8% of the total population.1 Fewer than 10% of dia-betics are estimated to have type 1 diabetes (T1D), while the remainder have type 2 diabetes (T2D).1,2 As diabetes disrupts the body’s ability to regulate blood glucose levels, management regimens aim to stabilize blood glucose by maintaining it at a healthy level.3 Typically, this involves a combination of drug therapy (e.g. insulin injections or oral medications), lifestyle modifications (i.e. proper nutrition, etc.), and the self-monitoring of blood glucose levels.4 Properly managing diabetes is essential to preventing possible health complications that arise from elevated blood glucose levels.Management regimens vary depending on both the type and severity of diabetes. While people with T1D depend on insulin therapy, people with T2D may be treated with oral glucose-lowering pills and/or insulin. Not all diabetics with T2D need drug therapy to manage blood glucose levels; some people achieve glycemic control by increasing exercise and modify-ing their diet. To assist in optimizing treatment, health care providers usually monitor a patient’s glycemic control using HbA1c tests. Patients are also com-monly instructed to self-monitor their blood glucose levels regularly as an important part of managing their diabetes.5Self-Monitoring Blood Glucose: Rethinking Current PracticeRoutine self-monitoring blood glucose (SMBG) has long been a cornerstone of daily self-management.5 This is especially true for diabetics using insulin, who may rely on SMBG to prevent hypoglycemia and accurately dose insulin boluses. SMBG involves several components, including lancets, disposable test strips, and a glucometer. Glucometer readings enable patients and their care providers to make informed decisions about changing drug therapy or altering dosages, as well as adjusting lifestyle factors. Over the long term, accurate glycemic control can help prevent health complications. Generally, test strips fit only their accompanying glucometers and have very limited interchangeability with other models. Test strips cannot be used with other brands of glucometers.Though the clinical benefit of SMBG is undisputed for diabetics treated with insulin, evidence to support the benefit of routine testing for diabetics not treated with insulin is lacking.4,6,7 Moreover, some research find-ings indicate that routine SMBG among non-insulin treated type 2 diabetics may be associated with higher levels of anxiety.8,9 Despite the lack of clear evidence and some suggestion of harm, several Canadian public drug benefit programs—including BC Pharmacare—currently offer unrestricted coverage for blood glucose test strips (BGTS) to all diabetic populations.Public Coverage for Test Strips in BCTest strips are listed as a benefit under three Phar-maCare plans: Fair PharmaCare, Plan C (Income Assistance), and Plan F (At Home Program). To be eligible for coverage under these public plans, an individual must meet two criteria. First, SMBG must be deemed medically necessary.10 A prescription is not required for this criterion to be met; rather, individu-als are referred to a Diabetes Education centre if SMBG is deemed clinically beneficial. Once this has been established, the individual must obtain a Certifi-cate of Training in Blood Glucose Monitoring issued UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CH7by a Diabetes Education Centre.10 After the certificate has been registered in the PharmaNet system an indi-vidual qualifies for ongoing coverage.  PharmaCare currently covers over 50 BGTS products. The public program reimburses the pharmacy’s actual acquisition cost, up to a predetermined maximum price per test strip for each approved product.10 The maximum price paid is based on the manufacturer’s list price plus a 7% mark-up.11 Test strip prices on the formulary range from $0.45 to $0.93 per individual strip. A dispensing fee is also reimbursed up to a maximum allowable fee of $10.00.12 Glucometers, in contrast, are not covered by Pharmacare. These devices are available over-the-counter (OTC) and cost $80 on average. As test strips fit an accompanying glucometer and are not compatible with other brands, manufacturers generally provide glucometers for free with the purchase of test strips to entice shoppers to use their products.   Cost Trends for Public Drug ProgramsOver the past decade, provincial governments have seen their expenditures on BGTS grow substantially.  An Ontario-based study by Gomes et al. found that BGTS use among patients aged 65 and over increased by 250% between 1997 and 2008.13 By 2008, BGTS expenditures in Ontario had reached over $100 million, making it the third largest expenditure of the Ontario Public Drug Programs (OPDP)—equivalent to 3.3% of total drug expenditures.13 Approximately 63% of these expenditures were attributable to diabet-ics not treated with insulin.13 Similarly, in British Columbia (BC), test strips were Pharmacare’s third highest expenditure in 2012.14 It is estimated that Pharmacare spends nearly $1 million per month in test strips for patients not treated with insulin.14 The anticipated future cost of these coverage policies is high. For example, researchers at the Institute for Clinical Evaluative Sciences (ICES) estimated in 2010 that if the Ontario public drug plan did not change its reimbursement policies, the program would spend roughly $500 million dollars on test strips over the following five year period.15 Substantial test strip expenditures could conceivably be expected in other jurisdictions, like BC, that have unrestrictive poli-cies. This in turn could lead to a “policy steal”; that is, resources available for more effective interventions or tools get displaced by the costs of comparatively lower-value SMBG test strip utilization.16Research ObjectivesGiven the high cost of SMBG test strip use, this study examined potential policy options that achieve reduc-tions in test strip use and costs. These policy options were designed to ensure coverage for the British Columbians who benefit most from SMBG test strip use. More specifically, the objectives of the research study were: 1. To examine the trends in test strip use among BC PharmaCare beneficiaries between 2004 and 2012, including variations in use by differ-ent groups of diabetics.2. To simulate the impacts and potential cost-savings of implementing quantity restrictions on test strip coverage in line with the Ontario Public Drug Programs’ (OPDP) quantity restrictions that became effective in August 2013.U T I L I Z A T I O N  PA T T E R N S  A N D  R E I M B U R S E M E N T  O P T I O N S  F O R  D I A B E T E S  T E S T  S T R I P S  I N  B C8BackgroundOverview of Current EvidenceUncertainty around the benefits of SMBG—par-ticularly for patients with T2D not treated with insulin—prompted the Canadian Agency for Drugs and Technologies in Health (CADTH) to conduct a systematic review, meta-analysis, and cost-effec-tiveness evaluation that was published in 2009.17 As part of this study, the COMPUS Expert Review Committee (CERC) reviewed the results of seven randomized control trials that compared SMBG use to non-use among diabetics not treated with insulin. This analysis concluded that SMBG is associated with a modest improvement (decrease of 0.25% in HbA1c) in glycemic control among patients not treated with insulin.17 Although this improvement was found to be statistically significant, it was deemed not to be clini-cally meaningful. The committee could not conclude with certainty that SMBG offers long-term benefits in terms of improved quality of life, health complica-tions, or mortality, as the evidence was sparse and inconsistent.17 Recent systematic reviews and meta-analyses—including a study by Malanda et al. of the Cochrane Collaboration—corroborate CADTH’s findings.6,7 Researchers sought to update an earlier Cochrane review published in 2005 and synthesize the clini-cal evidence. Six new randomized control trials that investigated the effects of SMBG use versus non-use among non-insulin-treated type 2 diabetics were added to the original review. Their analysis demon-strated that the benefits of SMBG compared to no SMBG for patients who have been living with type 2 diabetes for at least one year are statistically signifi-cant, but minimal; testing conferred an improvement in glycemic control (decrease of 0.3% in HbA1c) for up to six months, which ceased after 12 months.6        In terms of cost-effectiveness, CERC estimated that the incremental cost of routine SMBG—testing nine times per week—was $113,643 per QALY gained relative to no testing.18 Sensitivity analysis revealed that testing four times per week cost $46,445 per QALY gained and testing once per week cost $6,322 per QALY gained.18 The committee found that a reduction in testing frequency would likely improve cost-effectiveness, as would reducing the price per test strip. For example, at utilization rates of nine test strips per week, reducing the price per strip by 75% would reduce costs to $31,101 per QALY gained.18 CERC concluded that at current prices, routine SMBG among non-insulin treated patients is unlikely to be an efficient use of health care resources.Subsequent to CADTH’s study, ICES published findings from an investigation of test strip use and costs among diabetic patients over the age of 65 Ontario.19 ICES researchers examined trends across four diabetes therapy groups and found that test strip use increased substantially in all groups; the total number of test strips paid for between 1997 and 2008 increased almost five-fold: from 24.9 million strips to 117.6 million strips.19 They also formulated five policy scenarios that would restrict the number of test strip dispensed to different groups of patients and estimated the potential cost reductions. The first two scenarios were guided by CADTH’s optimal therapy recommendations, both of which allow unlimited test strip use among insulin-users and limit test strip payment to a maximum of 100 strips per year among all other therapy groups. The other three scenarios permitted unlimited use among insulin-users and users of hypoglycemia-inducing oral drugs, with reimbursement maximums ranging from 100, 200, and 400 strips per year among patients at low risk of hypoglycemia, respectively. ICES estimated that cost UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CH9reductions ranging from 8% to 63% could be achieved depending on the stringency of the reimbursement criteria.19 A recent report by the Patented Medicines Pricing Review Board (PMPRB) examined test strip use and cost in Saskatchewan, Manitoba, and Nova Scotia using data from 2008.20 Utilization data for three distinct therapy groups (i.e. insulin-only users, insulin and oral anti-diabetic drugs users, and non-users of insulin) were compared to test strip frequency recom-mendations made by CADTH in 2009, and the CDA in 2008 and 2011. Based on this comparison, PMPRB found that the majority of non-users of insulin (59% to 81%) tested in line with the CDA’s 2011 minimum government reimbursement recommendations of between 15 and 30 strips per month.20 PMPRB also compared the formulary prices of test strips between the provinces and three comparator countries, using the US Federal Supply Schedule (US FSS), and the United Kingdom and French formularies. Find-ings indicate that the three Canadian provinces pay significantly more than comparator countries for test strips ($0.73-$0.79 CAD).20 The provinces pay nearly twice as much as the average price listed on the US FSS ($0.39 CAD), and the substantially more than the average formulary prices in the UK and France ($0.56 CAD and $0.49 CAD, respectively).20     Optimal Therapy Recommendations and Clinical Practice GuidelinesThe optimal therapy recommendations that emerged from CADTH’s study are classified by diabetes type and course of treatment. These recommendations are summarized below in Table 1.At the time of publication, CERC’s recommendations were contrary to the prevailing clinical paradigm and existing practice guidelines; in particular, the guidance for patients not treated with insulin. Specifi-cally, CERC recommended that most adults using anti-diabetic drugs without insulin do not require routine SMBG. The committee noted, however, that select patients may need periodic testing. Patients might require more frequent testing under the fol-lowing conditions: (1) unstable glucose levels; (2) acute illness; (3) changes to drug therapy; (4) risk of hypoglycemia; (5) pregnancy; and (6) jobs where hypoglycemia poses danger.4 Under these conditions, CERC advised that testing should be linked to activi-ties such as preventing hypoglycemia or adjusting drug dosage. The committee recommended that most adults controlling their diabetes through diet do not require routine SMBG, noting that women who are pregnant or considering pregnancy may benefit from periodic testing.4Table 1. Summary of CERC optimal therapy recommendations Diabetes Therapy Group Optimal Frequency of SMBGAdults	and	children	with	T1D CERC	recommends	individualized	SMBGAdults	with	T2D	using	insulin	with	or	without	oral		anti-diabetic	drugsCERC	suggests	a	max	frequency	of	14	tests	per	weekAdults	with	T2D	using	anti-diabetic	drugs	(without		insulin)	or	no	anti-diabetic	drugsRoutine	SMBG	is	not	recommendedPeriodic	testing	for	select	patientsWomen	with	gestational	diabetes	not	using	anti-	diabetic	drugsCERC	recommends	individualized	SMBGU T I L I Z A T I O N  PA T T E R N S  A N D  R E I M B U R S E M E N T  O P T I O N S  F O R  D I A B E T E S  T E S T  S T R I P S  I N  B C1 0The CDA’s 2013 Clinical Practice Guidelines are more in line with CADTH’s optimal therapy recom-mendations than the previous 2008 guidelines. For example, the new guidelines indicate that infrequent SMBG is appropriate for some patients not treated with insulin.3 Table 2 below provides an overview of the CDA Clinical Practice Guideline Expert Commit-tee’s recommendations on the frequency of SMBG. A major difference between CADTH’s recommen-dations and the CDA’s guidelines is the distinction made between oral anti-diabetic drugs that pose risk of hypoglycemia versus those that do not. The Expert Committee suggested that increased frequency of SMBG may be required if a patient is treated with hypoglycemia-inducing anti-diabetic drugs, among other conditions summarized in the CDA’s Recom-mendation Tool for Healthcare Providers.21In terms of international guidelines, a recent post-market review by the Australian Department of Health and Ageing and the University of South Australia found that most guidelines by major international professional organizations and health Table 2. Summary of the CDA’s 2013 Clinical Practice GuidelinesDiabetes Therapy Group SMBG RecommendationIndividuals	with	T1D	using	insulin	more	than	once	a	dayThe	Expert	Committee	recommends	SMBG	at	least	3	times	per	day.Individuals	with	T2D	using	insulin	once	a	day	in	addition	to	oral	anti-diabetic	drugsThe	Expert	Committee	recommends	SMBG	at	least	once	a	day	at		variable	times.Individuals	with	T2D	not using insulinThe	Expert	Committee	recommends	individualized	SMBG	based	on		type	of	oral	anti-diabetic	drugs,	level	of	glycemic	control,	and	risk	of		hypoglycemia.When	glycemic	targets	are	not	being	met,	SMBG	should	be	introduced	and	should	include	periodic	pre-	and	postprandial	measurements,	as	well	as	training	on	how	to	modify	meds	and	lifestyle	according	to	glucometer	readings.When	glycemic	targets	are	being	met	or	anti-diabetic	drugs	do	not	pose	risk	of	hypoglycemia,	infrequent	SMBG	is	appropriate.technology assessment bodies note the lack of evidence to support routine SMBG by diabetics not treated with insulin.22 SMBG: The ControversyThe research findings outlined above have challenged the prior clinical paradigm on SMBG. The conclu-sions drawn from these studies have been met with substantial criticism. One major criticism has been that some randomized clinical trials included in the systematic reviews treat SMBG as an “unvarying medication or treatment”; that is, some studies divide participants into treatment and non-treatment groups without specifying the frequency of SMBG and use of glucometer readings.23 Critics have argued that SMBG is not inherently a uniform intervention. Rather, it is a tool that requires sufficient education and train-ing for both patients and health care providers to be effective.23 They highlight the need for well-designed clinical trials that involve structured SMBG, including a streamlined method of recording glucometer data and analyzing trends.UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CH1 1Within the Canadian context, CERC’s 2009 optimal therapy recommendations for SMBG were initially met with major pushback from the diabetic commu-nity. In 2010, the CDA publicly opposed Nova Scotia’s policy decision to restrict BGTS reimbursement based on CERC’s optimal therapy recommenda-tions.24 One key criticism by the CDA was that cost-effectiveness was weighted too heavily compared to clinical effectiveness in CERC’s optimal therapy recommendations.25 Another criticism was that the recommendations did not differentiate between oral glucose-lowering drugs that pose a higher risk for developing hypoglycemia. While the CDA has since revised its clinical practice guidelines, the organi-zation disagrees with the framing of SMBG as an intervention.3,25 Rather, the CDA believes that SMBG should be viewed as a tool to inform the use of other interventions.U T I L I Z A T I O N  PA T T E R N S  A N D  R E I M B U R S E M E N T  O P T I O N S  F O R  D I A B E T E S  T E S T  S T R I P S  I N  B C1 2Jurisdictional Overview: Existing Public Coverage PoliciesCanadian Patient Eligibility Criteria and BenefitsAll Canadian provinces offer some level of public coverage for test strips. However, individual patient eligibility criteria, benefits, and the approved products for coverage differ considerably, as shown in Table 3. Although prescriptions are a common requirement to obtain test strip coverage, some variations exist in terms of which health care providers are authorized to prescribe test strips. Prescriptions are not required to obtain test strip coverage in BC or Saskatchewan. However, a Certificate of Training from an approved Diabetes Education Centre is required for coverage  in BC.Nearly all provinces offer some level of public cover-age to non-insulin treated diabetics. One notable exception is the drug program in PEI. When test strip coverage was first introduced in PEI in 2008, it was made available only to patients treated with insulin. Of the nine provincial programs that cover test strips for non-insulin treated diabetics, BC, Nova Scotia, Quebec, and Saskatchewan offer unrestricted benefits. Manitoba and Newfoundland and Labrador cap yearly benefits uniformly across diabetes therapy regimens, whereas yearly caps in Alberta, New Brunswick, and Ontario vary based on diabetes therapy regimen.Table 3. Summary of patient eligibility criteria and yearly benefitsProvince Patient Eligibility Criteria Benefit (per year)Prescription	RequiredOtherAlberta Yes Varies	between	plans Varies	between	plans;	AMFH	program	caps	benefit	at	$100,	$250,	$600	per	year	depending	on	diabetes	therapy	regimenBritish	Columbia No SMBG	must	be	deemed	medically	necessary	and	have	a	Certificate	of	Training	from	an	approved	Diabetes	Education	CentreOngoing	coverageManitoba Yes N/A 4,000	strips	per	yearNew	Brunswick Yes Must	qualify	for	a	health	card	issued	by	the	Department	of	Social	Development	and	obtain	a	pharmacy	estimate50,	100,	or	individualized	number	of	strips	per	year	depending	on	diabetes	therapy	regimenNewfoundland	and	LabradorYes Providers	must	obtain	special	authoriza-tion	from	the	Department	of	Health	and	Community	Services	if	there	is	no	history	of	insulin	or	oral	diabetic	medications2,500	strips	per	yearNova	Scotia Yes N/A Limited	to	the	amount	prescribedOntario Yes N/A 200,	400,	or	3,000	strips	per	year	depending	on	diabetes	therapy	regimenPrince	Edward	IslandYes Must	be	eligible	for	the	Diabetes	Program	and	using	insulin	within	the	last	150	days1,200	strips	per	year*Quebec Yes N/A Limited	to	the	amount	prescribedSaskatchewan No N/A Ongoing	coverage*	Maximum	of	100	test	strips	per	30	daysUBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CH1 3Table 4. Summary of provincial test strip reimbursementProvince Benefit Price (Max  Reimbursement)Ingredient Price (cents per strip)Dispen-sing FeeMax Dispensing  FeeAlberta Retail	price	claimed N/A No N/ABritish	Columbia MLP	+	8%	mark-up $0.41-$0.86 Yes $10.00Manitoba Acquisition	cost	through	wholesaler	(McKesson	Canada)N/A Yes No	cap;	usual	and	customary	appliesNew	Brunswick Individual	pharmacy	price	quotes	approved	by	Dept.	of	Social	DevelopmentN/A No N/ANewfoundland	and	LabradorMLP	+	8.5%	mark-up $0.38-$0.94 Yes $11.05	for	drug	costs	up	to	$49,	$22.55	for	drug	costs	between	$50	and	$249.99Nova	Scotia Pharmacare	Reimbursement	Price	(PRP)	up	to	0.7400	cents	per	strips	+	6%	mark-up$0.39-$0.74 Yes $12.10Ontario MLP	+	8%	mark-up	up	to	0.7290	cents		per	strip$0.37-$0.68 Yes $8.62Prince	Edward	IslandMLP	+	10%	mark-up N/A No N/AQuebec MLP	+	6.5%	mark-up $0.40-$0.73 Yes New	prescription:	$9.16;	repeat:	$8.78Saskatchewan Based	on	total	cost	(MLP	+	8.5%	mark-up	+	tiered	pharmacy	mark-up	+	dispensing	fee)$0.42-$0.82 Yes $10.75Benefit Prices and Dispensing FeesConsiderable variations exist in terms of the benefit price—or maximum reimbursement amount—paid by each of the provincial drug programs for approved products. These differences are summarized below in Table 4. BC, Newfoundland and Labrador, Prince Edward Island, and Quebec reimburse the manufac-turer’s list price plus a maximum allowable mark-up, which ranges from 6.5% to 10%. Ontario reimburses the manufacturer’s list price plus a maximum mark-up of 8% up to the Maximum Allowable Reimburse-ment (MAR) price of 0.7290 cents per strip. Nova Scotia reimburses the Pharmacare Reimbursement Price (PRP), which is based on the manufacturer’s list price, up to 0.7400 cents per strip plus a 6% mark-up. Test strip reimbursement in Saskatchewan is based on total cost, which includes the manufacturer’s list price, an 8.5% wholesale mark-up, a tiered pharmacy mark-up, and the dispensing fee. Alberta reimburses the retail price claimed up to the maximum yearly benefit amount of $100, $250, or $600 per year. New Brunswick’s Department of Social Development does not have an explicit pricing policy, but does require a pharmacy price quote; case managers are guided by what is informally considered “usual and customary” pharmacy prices for test strips. Dispensing fees apply to test strips in most prov-inces and are covered by the public programs up to a maximum fee. As described in Table 4, maximum dis-pensing fees vary to a great extent, ranging from $8.62 to $22.55 per prescription filled. The public programs in Alberta, New Brunswick, and Prince Edward Island do not cover dispensing fees for test strips, as the fees do not apply. MLP:	Manufacturer	list	priceU T I L I Z A T I O N  PA T T E R N S  A N D  R E I M B U R S E M E N T  O P T I O N S  F O R  D I A B E T E S  T E S T  S T R I P S  I N  B C1 4International ContextPatient	Eligibility	Criteria	and	BenefitsReimbursement policies for test strips vary to a great extent between countries, as well between regions within countries.26 We examined test strip public coverage policies in the following six countries: the United States, the United Kingdom, Sweden, the Netherlands, Australia, and New Zealand. Much like in Canada, prescriptions are commonly required to obtain test strip coverage and variation exists in terms of which health care professionals are authorized to prescribe test strips between countries.Table 5 outlines additional eligibility criteria and test strip benefits in each country. All countries examined offer some level of public coverage to non-insulin treated diabetics. Benefits vary between countries and between regions within countries, namely in the UK, the Netherlands, and for US Veterans Affairs. Unrestricted benefits are available non-insulin treated patients in Sweden and to patients registered with Australia’s National Diabetes Services Scheme (NDSS).22 Australia’s Pharmaceutical Benefits Scheme (PBS) caps benefits uniformly across diabetes therapy regimens, but imposes distinct limits for patients receiving treatment under a GP Management Plan or Team Care Arrangement.22 The US Centres for Medicare and Medicaid Services and the New Zealand restrict the quantity of test strips based on diabetes therapy regimen.27,28 Benefit	Prices	and	Dispensing	FeesConsiderable variations exist in terms of benefit price paid by each country for approved products. Table 6 summarizes these differences. New Zealand, and the UK reimburse the manufacturer’s list price. Australia and Sweden reimburse the manufacturer’s list price, plus allowable mark-ups. US Veterans Affairs negoti-ates prices in the same way as other pharmaceutical products. The price reimbursed by the US Centres for Medicare and Medicaid Services was achieved through a competitive bidding process.29 Dispensing fees apply to test strips in all but two programs: US Veterans Affairs and US Centres for Medicare and Medicaid Services. The maximum dispensing fees vary by region or contractor in New Zealand and the UK, respectively. UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CH1 5Country and ProgramPatient Eligibility Criteria BenefitPrescription	RequiredOtherUS	Veterans	AffairsYes Varies	by	Veterans	Integrated	Service	Network	(VISN)	Varies	by	Veterans	Integrated	Service	Network	(VISN)US	Centres	for	Medicare	and	Medicaid	ServicesYes Prescription	must	containing	the	following	information:	(1)	Whether	the	beneficiary	has	diabetes;	(2)	What	kind	of	blood	sugar	monitor	the	beneficiary	needs	and	why	they	need	it	(e.g.	if	special	monitor	is	needed	because	of	vision	problems,	the	doctor	must	explain	it.);	(3)	Whether	the	benefi-ciary	uses	insulin;	(4)	How	often	the	benefi-ciary	should	test	their	blood	sugar;	(5)	How	many	test	strips	and	lancets	the	beneficiary	needs	for	one	month.1,200	strips	per	year	for	insulin-users	and	400	strips	per	year	for	non-insulin-usersNew	Zealand Yes Only	the	CareSens	meters	and	test	strips	are	reimbursed,	with	the	following	excep-tions,	which	require	special	authorization:	(1)	Patients	using	an	Accu-Chek	Performa	meter	with	an	Accu-Chek	Combo	insulin	pump	before	1	June	2012.	(2)	Patients	using	a	Freestyle	Optium	meter	and	receiving	prescriptions	for	both	blood	glucose	and	ketone	testing	before	1	June	2012.	(3)	Visually	impaired	patients	are	eligible	for	the	SensoCard	Plus	Talking	Blood	Glucose	Meter.Maximum	quantity	of	50	strips	per	prescrip-tion.	Additional	strips	are	available	with	a	prescription	to	the	following	groups:	(1)	Patients	prescribed	insulin	or	a	sulphonyl-urea;	(2)	Pregnant	women	with	diabetes;	(3)	Patients	on	home	TPN	at	risk	of	hypogly-cemia	or	hyperglycemia;	(4)	Patients	with	a	genetic	or	an	acquired	disorder	of	glucose	homeostasis	excluding	type	1	or	type	2	diabetes	and	metabolic	syndrome.Netherlands Yes Reimbursement	limits	vary	between	health	insurance	providers,	which	set	their	own	policies,	but	typically	a	maximum	of	30	strips	per	month	are	reimbursed	to	indi-viduals	treated	with	oral	anti-diabetic	drugs.	Insulin-treated	individuals	receive	ongoing	coverage	for	strips.UK Yes Clinical	Commissioning	Groups	(CCG)	may	put	local	restrictions	on	test	stripsAustralia:	Pharmaceu-tical	Benefits	SchemeYes To	access	more	than	the	standard	five	repeats,	patients	must	be	treated	under	a	GP	Management	Plan	or	Team	Care	Arrangement.Accu-Chek	Mobile	test	strips	are	only		available	to	patients	treated	with	insulin.Maximum	quantity	of	one	pack	of	100	test	strips	plus	five	repeats	per	prescription.	People	receiving	treatment	under	a	GP	Management	Plan	or	Team	Care	Arrange-ment	are	eligible	to	receive	a	maximum	quantity	of	one	pack	plus	11	repeats.Australia:	National	Diabetes	Services	Scheme	(NDSS)No Registration	under	the	scheme Ongoing	coverageSweden Yes N/A Ongoing	coverageTable 5. Summary of patient eligibility criteria and yearly benefitsU T I L I Z A T I O N  PA T T E R N S  A N D  R E I M B U R S E M E N T  O P T I O N S  F O R  D I A B E T E S  T E S T  S T R I P S  I N  B C1 6Table 6. Summary of international test strip reimbursementCountry and ProgramBenefit Price (Max  Reimbursement)Ingredient Price ($CAD per strip)Dispensing  FeeMax Dispensing  FeeUS	Veterans	Affairs Federal	Supply	Schedule		negotiated	prices$0.15-$0.45 No N/AUS	Centres	for	Medicare	and	Medicaid	Services$10.41	per	package	of	50	strips $0.22 No N/ANew	Zealand MLP $0.17-$0.47 Yes Varies	by	regionUK MLP $0.23-$0.53 Yes Varies	by	contractorAustralia PBS	price	=	(MLP	+	7.52%	whole-saler	mark-up)	+	$4.50	(AUD)	pharmacy	mark-up	+	$6.63	(AUD)	dispensing	fee$0.37-$0.74 Yes/No $6.63	(AUD)Sweden AUP	plus	VAT $0.29-$0.51 Yes VariesMLP:	Manufacturer’s	list	priceAUP:	Apotekets	utförsäljningspris		VAT:	Value	added	taxUBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CH1 7Data Sources and MethodologyStudy DesignWe used a retrospective serial cross-sectional study design and examined administrative data between 2004 and 2012.30Data SourcesWe used PharmaNet data to examine the current level of test strip use and coverage in BC, and to simu-late the impact of different potential policy changes. The PharmaNet30 database contains comprehensive information about all prescriptions dispensed in BC. Three key components of the database were used in this study: (1) drug product data; (2) patient, pre-scriber, and pharmacy profile information; and (3) cost-related data. Data were used to define diabetes treatment groups, distributions, maximum reim-bursement levels, means and quintiles, and identify dispensing fees and costs to both public and private payers.To conduct an international comparison of test strip prices, we assembled publicly available price infor-mation obtained through several online sources. As a starting point, we sought price information for the United States and the United Kingdom, as these countries were included in a recent study by the Pat-ented Medicine Prices Review Board (PMPRB) that examined international test strip prices in 2008. As the French data source used by the PMPRB was no longer available at the time of our study, we were not able to include these prices in our comparative analysis. Price information for the US and UK was obtained from the United States Federal Supple Schedule and the United Kingdom Formulary through www.mims.co.uk. We also examined prices in New Zealand, Aus-tralia, Sweden, and the US Centre for Medicare and Medicaid, using data from the Pharmac Schedule, the Pharmaceutical Benefits Scheme (PBS), the Tand-vårdsoch läkemedelsförmånsverket (TLV) formulary, and the DMEPOS Competitive Bidding Program’s National Mail-Order single payment amount, respec-tively. All prices were retrieved in August 2013.Study Population and Diabetes Therapy GroupsWe studied BC PharmaCare beneficiaries over the age of 18 who received at least one prescription for blood glucose test strips between January 1, 2004 and December 31, 2012. Individuals prescribed test strips were assigned to one of four mutually exclusive diabetes therapy groups based on their medication use in each year. The diabetes therapy groups (Table 7) mirror those used in the ICES study in 2009 and those in CDA’s recommendations, which differentiate between  hypoglycemic inducing and non- hypo-glycemic inducing oral drugs.19,25 Individuals who received at least one prescription for oral glucose-lowering drugs, but not prescribed insulin, were Table 7. Diabetes therapy groupsTreatment Group Description1	–	Insulin	only One	or	more	prescriptions	for	insulin2	–	Hypoglycemia-inducing	oral	drugs One	or	more	prescriptions	for	an	oral	glucose-lowering	drug	with	a	higher	risk	of	hypoglycemia	in	year,	no	insulin3	–	Non-hypoglycemia	inducing	oral	drugs One	or	more	prescriptions	for	an	oral	glucose-lowering	drug	with	a	lower	risk	of	hypoglycemia	in	year,	no	insulin4	–	No	glucose-lowering	drug	treatment No	prescriptions	for	either	insulin	or	oral	diabetes	drugsU T I L I Z A T I O N  PA T T E R N S  A N D  R E I M B U R S E M E N T  O P T I O N S  F O R  D I A B E T E S  T E S T  S T R I P S  I N  B C1 8Table 8. Test strip quantity restriction scenario by diabetes therapy groupOntario Recommendations Model Quantity LimitInsulin	users:	3000	strips	annually 3000	strips	annually	(30	Rxs)Hypoglycemia-inducing	oral	glucose-lowering	drug	users:	400	strips	annually 400	strips	annually	(4	Rxs)All	other	patients:	200	strips	annually 200	strips	annually	(2	Rxs)stratified into either Groups 2 or 3, based on the risk of drug-induced hypoglycemia (list of drugs available in Appendix 2). Group 4 consisted of individuals who received at least one prescription for test strips, but who did not received a prescription for oral glucose-lowering drugs or insulin. Descriptive statistics for each diabetes therapy group, including the number of patients, total number of test strips dispensed and total cost, formed the basis of the scenario simulations.Test Strip Utilization and CostTo determine the overall level of test strip utilization, we calculated the number of test strips dispensed per calendar year of the study period, both overall and stratified by diabetes therapy group. We also calcu-lated the total Pharmacare costs paid for test strips per year, which includes the drug (or product) costs paid plus professional (dispensing) fees.      Reimbursement Restriction ScenarioUsing the Ontario Public Drugs Programs’ 2013 test strip quantity limits, we developed a test strip quantity restriction scenario to compare to the status quo. The scenario, outlined in Table 8, was used to simulate the cost-savings of adopting different quantity restrictions per benefit year.    For this simulation, we calculated the overall reduc-tion in test strip utilization and associated cost-savings per year from 2004 to 2012. Reductions in test strip use were estimated by applying limits to the amount of test strips dispensed per patient per year. In cases where patients had been dispensed fewer test strips than the limit in a given year, the dispensing amount remained unchanged. Total public costs were calcu-lated by adding both the product cost and dispensing cost paid by PharmaCare. International Price ComparisonsThe top ten test strip brands were determined by analyzing the volume of strips dispensed in 2012. The price per strip of the ten most commonly used brands were then compared against prices for the same brand in the formularies for six drug programs in five coun-tries—Australia, New Zealand, Sweden, UK, US CMS, and US VA.    UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CH1 9ResultsTest Strip Utilization and CostOverall, during the study period, test strip use has increased in BC. Within the BC PharmaCare program, the total number of SMBG test strips dispensed to individuals 18 and older between 2004 and 2012 increased by 28%, from 26.4 million to 33.7 million (Figure 1). However, since 2010, SMBG utilization has shown been decreasing. After reaching a peak of 36.2 million strips dispensed in that year, the total number has decreased by approximately 4% each year since. Similarly, the annual cost of SMBG test strips paid for by PharmaCare increased by 22% over the study period, from $18.4 million to $22.6 million. In 2012 this represented $21.2 million in product costs and $1.4 million in dispensing fee costs.SMBG	Use	by	Diabetes	Therapy	GroupsWe analysed test strip utilization within four different therapy groups; (1) insulin users, (2) patients taking hypoglycemia-inducing oral glucose-lowering drugs, Figure 1. Annual number and total cost of blood glucose test strips dispensed to patients aged 18 years and older covered by the PharmaCare program in BC, 2004 to 2012(3) patients taking non- hypoglycemia-inducing oral glucose-lowering drugs, and (4) patients treating with no glucose-lowering drug. Across all therapy groups, the number of patients aged 18 years or older using SMBG test strips that were recorded in PharmaNet increased by 36%, from 100,576 patients in 2004 to 136,659 patients in 2012.In 2012, 85% (N=44,256 of 51,885) of the included patients taking insulin received test strips. 61% (N=30,851 of 50,434) of those taking hypoglycemia-inducing oral glucose-lowering drugs, and 54% (N=35,066 of 64,866) of the patients taking non- hypoglycemia-inducing oral glucose-lowering drugs received SMBG test strips, in the same year (Figure 2). Note that it is not possible to include individuals treat-ing their diabetes without a glucose-lowering drug in this figure, as it was not possible to identify these patients based on diabetes pharmacotherapy.010203040$0$10$20$30$40Number of test strips dispensed (millions)Cost of test strips dispensed (millions)Total cost of test strips dispensed (millions)201220112010200920082007200620052004$0$3$6$9$12$15201220112010200920082007200620052004Proportion of patients using test strips0%20%40%60%80%100%20122011201020092008200720062005200426.429.331.0 32.233.734.9 36.2 35.0 33.7$18.4$19.9 $20.9$21.7 $22.6$23.4 $24.4 $23.4 $22.6InsulinHypoglycemia-inducing oral drug therapyNo glucose-lowering drug therapyCost of test strips dispensed (millions)Projected cost of test strips (millions)$0$5$10$15$20$25OntarioPolicyCurrentutilizationOntario PolicyCurrent utilization$21.2$1.4$17.0$1.2Non-hypoglycemia-inducing oral drug therapyInsulinHypoglycemia-inducing oral drug therapyNon-hypoglycemia-inducing oral drug therapy$0$5$10$15$20$25$302017201620152014201320172016201520142013$25,132,199$24,617,032$24,101,865$23,586,698$23,071,530$20,331,386$19,903,795$19,476,203$19,048,612$18,621,021$97,381,017$120,509,324Product costDispensing costU T I L I Z A T I O N  PA T T E R N S  A N D  R E I M B U R S E M E N T  O P T I O N S  F O R  D I A B E T E S  T E S T  S T R I P S  I N  B C2 0Figure 2. Proportion of patients aged 18 and older with diabetes using blood glucose test strips, by diabetes therapy group, in BC, 2004 to 2012 Figure 3. Annual PharmaCare cost of blood glucose test strips dispensed to patients aged 18 and older with diabetes, by diabetes therapy group, in BC, 2004 to 2012010203040$0$10$20$30$40Number of test strips dispensed (millions)Cost of test strips dispensed (millions)Total cost of test strips dispensed (millions)201220112010200920082007200620052004$0$3$6$9$12$15201220112010200920082007200620052004Proportion of patients using test strips0%20%40%60%80%100%20122011201020092008200720062005200426.429.331.0 32.233.734.9 36.2 35.0 33.7$18.4$19.9 $20.9$21.7 $22.6$23.4 $24.4 $23.4 $22.6InsulinHypoglycemia-inducing oral drug therapyNo glucose-lowering drug therapyCost of test strips dispensed (millions)Projected cost of test strips (millions)$0$5$10$15$20$25OntarioPolicyCurrentutilizationOntario PolicyCurrent utilization$21.2$1.4$17.0$1.2Non-hypoglycemia-inducing oral drug therapyInsulinHypoglycemia-inducing oral drug therapyNon-hypoglycemia-inducing oral drug therapy$0$5$10$15$20$25$302017201620152014201320172016201520142013$25,132,199$24,617,032$24,101,865$23,586,698$23,071,530$20,331,386$19,903,795$19,476,203$19,048,612$18,621,021$97,381,017$120,509,324Product costDispensing cost010203040$0$10$20$30$40Number of test strips dispensed (millions)Cost of test strips dispensed (millions)Total cost of test strips dispensed (millions)201220112010200920082007200620052004$0$3$6$9$12$15201220112010200920082007200620052004Proportion of patients using test strips0%20%40%60%80%100%20122011201020092008200720062005200426.429.331.0 32.233.734.9 36.2 35.0 33.7$18.4$19.9 $20.9$21.7 $22.6$23.4 $24.4 $23.4 $22.6InsulinHypoglycemia-inducing oral drug therapyNo glucose-lowering drug therapyCost of test strips dispensed (millions)Projected cost of test strips (millions)$0$5$10$15$20$25OntarioPolicyCurrentutilizationOntario PolicyCurrent utilization$21.2$1.4$17.0$1.2on-hypoglycemia-inducing oral drug therapyInsulinHypoglycemia-inducing oral drug therapyNon-hypoglycemia-inducing oral drug therapy$05$105205302017201620152014201320172016201520142013$25,132,199$24,617,032$24,101,865$23,586,698$23,071,530$20,331,386$19,903,795$19,476,203$19,048,612$18,621,021$97,381,017$120,509,324Product costDispensing costUBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CH2 1SMBG	Cost	by	Diabetes	Therapy	GroupsAs shown in Figure 3 and Table 9, the largest increase in total PharmaCare SMBG costs occurred among patients using insulin (43% increase, from $9.3 million in 2004 to $13.3 million in 2012), followed by non-hypoglycemia-inducing oral glucose-lowering drugs (25% increase, from $2.7 million in 2004 to $3.4 million in 2012). PharmaCare SMBG costs decreased over the study period among patients using hypo-glycemia-inducing oral glucose-lowering drugs (8% decrease, from $5.0 million in 2004 to $4.6 million in 2012), and those with no glucose-lowering therapy (9% decrease, from $1.5 to $1.3 million).Reimbursement Restriction ScenarioWe modeled a quantity limit scenario based on the Ontario 2013 Policy (described above). We found that the Ontario Policy would impact 12% of the SMBG testing population (see Table 10).The potential cost reduction from quantity limits based on 2012 utilization was $4.4 million when we applied the Ontario Policy (see Table 11). In this scenario, patients in the non- hypoglycemia-inducing oral drug and hypoglycemia-inducing oral drug therapy groups would have been impacted more than those on insulin or not on a glucose-lowering therapy at all.Table 9. Blood glucose test strip utilization and costs, for patients aged 18 years and older, for the BC PharmaCare program, calendar year 2012N (%) PatientsN (%) SMBG ClaimsN (%) SMBG Strips DispensedN (%) SMBG Strips Pharmacare PaidTotal Cost of SMBG StripsTotal	Cost	of	StripsProduct	CostDispensing	CostInsulin44,256	(32%) 228,582(53%) 34,791,488	(57%) 20,517,199	(61%) $13,269,422 $12,495,981 $773,441Hypoglycemia-inducing	oral	glucose-lowering	drugs30,851	(23%) 80,893	(19%) 10,574,559	(17%) 6,438,663	(19%) $4,575,495 $4,268,052 $307,443Non-hypoglycemia-inducing	oral	glucose-lowering	drugs35,066	(26%) 77,796	(18%) 9,645,968	(16%) 4,823,943	(14%) $3,379,675 $3,148,549 $231,126No	glucose-lowering	drug	therapy26,486	(19%) 47,684	(11%) 5,708,886	(9%) 1,943,321(6%) $1,331,770 $1,243,224 $88,547Table 10. Number of patients impacted by the Ontario scenario, based on diabetes therapy group, in 2012Therapy Group Current OntarioNumber	of	Patients Number	ImpactedInsulin 44,256 549Hypoglycemia-inducing	oral	glucose-lowering	drugs 30,851 5,484Non-hypoglycemia-inducing	oral	glucose-lowering	drugs 35,066 7,424No	drug	therapy 26,486 2,781Total 136,659 16,238%	of	Patients	Impacted – 12%U T I L I Z A T I O N  PA T T E R N S  A N D  R E I M B U R S E M E N T  O P T I O N S  F O R  D I A B E T E S  T E S T  S T R I P S  I N  B C2 2Table 11. Reduction in utilization and cost associated with the Ontario policy scenario related to testing frequency, for patients aged 18 years and older, in BC, calendar year 2012Calendar Year 2012 Ontario PolicyNo.	Patients No.	Strips Total	CostNo.	Patients	Impacted No.	Strips Total	CostInsulin44,256 20,517,199 $13,269,422 549 20,105,800 $13,023,783Hypoglycemia-inducing	oral	glucose-lowering	drugs30,851 6,438,664 $4,575,495 5,484 4,121,011 $2,919,917Non-hypoglycemia-inducing	oral	glucose-lowering	drugs35,066 4,823,943 $3,379,675 7,424 2,249,630 $1,573,067No	glucose-lowering	drug	therapy26,486 1,943,321 $1,331,770 2,781 987,552 $676,662Total136,659 33,723,127 $22,556,363 16,238 27,463,993 $18,193,430Total	Reduction	– 	– 	– 	– 6,259,133 $4,362,933If BC were to implement SMBG test strip limits for insulin users, the savings increase as the limit is lowered. The Ontario Policy allows for 3,000 strips per year (over 8 strips per day) and in 2012 would only have impacted 549 British Columbians using insulin, and resulted in $245,639 in savings. Other programs have instituted more strict guidelines. For example, the Non-Insured Health Benefits (NIHB) program has adopted a policy that more closely reflects the CERC Recommendations and limits SMBG test strip use Table 12. Estimates on test strip limits for insulin users, for patients aged 18 years and older, in BC, in 2012Test Strip Limit for Insulin UsersNumber of Patients Impacted in BC in 2012Estimated Total CostTotal Savings2,000 2,075 $12,497,693.46 $771,728.983,000 549 $13,023,783.27 $245,639.174,000 169 $13,178,618.11 $90,804.345,000 70 $13,234,979.11 $34,443.336,000 24 $13,256,620.31 $12,802.13for insulin users to 1,825 strips per year (five strips per day).31 Table 12 shows the number of patients impacted and savings from different test strip limits for insulin users. Limiting BC reimbursement to 2,000 strips per year (an average of 5.5 strips per day) would have impacted 2,075 British Columbians in 2012 and saved $771,728. Increasing the limit to 4,000 strips per year would significantly lower the number of patients impacted to 169, but would also decrease the savings.UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CH2 3Potential	Impacts	of	Quantity	LimitsQuantity limits would produce savings in terms of both products costs and dispensing fees, as some patients would qualify for fewer refills (see Figure 4). Applying the Ontario Policy to 2012 test strip utiliza-tion would have produced over $4 million in product cost savings, and $200,000 in dispensing cost savings.If current testing patterns continue, we project that the total cost of SMBG will exceed $120 million dollars over the next five years (see Figure 5). Our projections based on current trends in utilization estimate that the Ontario 2013 Policy would reduce the costs for SMBG test strips by at least $23 million in BC over the next five years.Figure 4. Costs of blood glucose test strips associated with the Ontario scenario related to testing frequency, in patients aged 18 years and older, in BC, calendar year 2012010203040$0$10$20$30$40Number of test strips dispensed (millions)Cost of test strips dispensed (millions)Total cost of test strips dispensed (millions)201220112010200920082007200620052004$0$3$6$9$12$15201220112010200920082007200620052004Proportion of patients using test strips0%20%40%60%80%100%20122011201020092008200720062005200426.429.331.0 32.233.734.9 36.2 35.0 33.7$18.4$19.9 $20.9$21.7 $22.6$23.4 $24.4 $23.4 $22.6InsulinHypoglycemia-inducing oral drug therapyNo glucose-lowering drug therapyCost of test strips dispensed (millions)Projected cost of test strips (millions)$0$5$10$15$20$25OntarioPolicyCurrentutilizationOntario PolicyCurrent utilization$21.2$1.4$17.0$1.2Non-hypoglycemia-inducing oral drug therapyInsulinHypoglycemia-inducing oral drug therapyNon-hypoglycemia-inducing oral drug therapy$0$5$10$15$20$25$302017201620152014201320172016201520142013$25,132,199$24,617,032$24,101,865$23,586,698$23,071,530$20,331,386$19,903,795$19,476,203$19,048,612$18,621,021$97,381,017$120,509,324Product costDispensing costFigure 5. Projected total costs of blood glucose test strips associated with the Ontario scenario related to testing frequency, in patients aged 18 year  and older, in BC, calendar years 2013  to 2017 010203040$0$10$20$30$40Number of test strips dispensed (millions)Cost of test strips dispensed (millions)Total cost of test strips dispensed (millions)201220112010200920082007200620052004$0$3$6$9$12$15201220112010200920082007200620052004Proportion of patients using test strips0%20%40%60%80%100%20122011201020092008200720062005200426.429.331.0 32.233.734.9 36.2 35.0 33.7$18.4$19.9 $20.9$21.7 $22.6$23.4 $24.4 $23.4 $22.6InsulinHypoglycemia-inducing oral drug therapyNo glucose-lowering drug therapyCost of test strips dispensed (millions)Projected cost of test strips (millions)$0$5$10$15$20$25OntarioPolicyCurrentutilizationOntario PolicyCurrent utilization$21.2$1.4$17.0$1.2Non-hypoglycemia-inducing oral drug therapyInsulinHypoglycemia-inducing oral drug therapyNon-hypoglycemia-inducing oral drug therapy$0$5$10$15$20$25$302017201620152014201320172016201520142013$25,132,199$24,617,032$24,101,865$23,586,698$23,071,530$20,331,386$19,903,795$19,476,203$19,048,612$18,621,021$97,381,017$120,509,324Product costDispensing costU T I L I Z A T I O N  PA T T E R N S  A N D  R E I M B U R S E M E N T  O P T I O N S  F O R  D I A B E T E S  T E S T  S T R I P S  I N  B C2 4Table 13. Comparison of international prices for top ten test strip brands in BC, by utilization, January 2014 pricesBrand name BC PharmaCare Min Int’l ($CAD) Program % DifferenceOne	Touch	Ultra $0.67 $0.22 US	CMS -	68%Ascensia	Contour $0.68 $0.22 US	CMS -	68%Accu-Chek	Aviva $0.69 $0.22 US	CMS -	69%Accu-Chek	Compact $0.71 $0.51 UK -	28%Freestyle	Lite $0.67 $0.19 US	VA -	71%Ascensia	Microfill $0.73 - - -Ascensia	Breeze	2 $0.69 $0.22 US	CMS -	68%One	Touch	Verio $0.68 $0.48 UK -	29%Bayer	Contour	Next $0.69 $0.36 SWE -	48%One	Touch $0.68 $0.47 UK -	31%International Price ComparisonsAs shown in Table 13, we found that international prices were substantially lower for the top ten most commonly used brands of test strips in BC. For example, One Touch Ultra test strips—which account for over one third of all test strips used in BC—are reimbursed at rates 68% lower in public insurance programs in the United States. Further, nine out of the top ten strips were sold in other countries, and in every instance they were available at lower costs than in BC.UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CH2 5DiscussionPolicy ImplicationsAt the current utilization rate, we found that the costs of blood glucose test strips will likely exceed $120 million to the BC PharmaCare program over the next five years. Implementing quantity limits similar to those implemented in Ontario in 2013 could stem these costs by more than $23 million over the same time frame. As this policy was only implemented by Ontario in August of 2013, it will also be important to monitor and consider the evidence on implications for both patient care and costs of this policy change.Further, using international price comparisons, we found that BC is currently paying more for diabetes test strips than other jurisdictions. Any policy change for blood glucose test strip cover-age will require engagement with stakeholder groups, and in particular clear communication and doctors and pharmacists who will be prescribing and dispens-ing strips to patients. A change in coverage will no doubt elicit questions and concerns from patients, so medical professionals will need to be prepared and supported to adequately respond.Challenges and OpportunitiesMany Canadian provinces have implemented new policies surrounding blood glucose test strip use in recent years, meeting varied responses from the public. Nova Scotia attempted to implement new quantity restrictions that reflected the CERC recom-mendations; however, there was no consultation with stakeholder groups before the policy was announced. The proposed policy was quickly rescinded and no subsequent policies to limit test strip utilization have been implemented.32 The CERC recommendations may have been seen as too restrictive, but the CDA guidelines have been met with more openness. When Ontario introduced their quantity restriction policy in August 2013, they did not encounter the same resis-tance as Nova Scotia. This could be credited partly to their policies consistencies with CDA guidelines.Price negotiations in other jurisdictions have involved the use of exclusive listing agreements in order to achieve large cost reductions. For example, in 2012 the Pharmaceutical Management Agency (PHARMAC) in New Zealand, announced the sole listing of Care-Sens blood glucose meters and test strips.33 The move to sole sourcing was estimated to save $10 million NZD, annually—nearly half of the $22 million NZD in subsidies that PHARMAC was paying for diabetes test strips.34LimitationsThere are two key limitations to this study. First of all, the number of test strips dispensed does not necessar-ily equal the number of test strips used. It is possible that patients could stockpile or sell test strips, or give them to others who do not have pharmaceutical prescription coverage. However, it is important to note that such activities would not change the results of our simulations in terms of the impact on cost and quan-tity of test strips reimbursed. The second limitation is that the scenarios calculated do not account for excep-tions that would likely be made a component of any policy change. Such exceptions, of course, would both cost resources to process and lead to higher utilization than calculated above. U T I L I Z A T I O N  PA T T E R N S  A N D  R E I M B U R S E M E N T  O P T I O N S  F O R  D I A B E T E S  T E S T  S T R I P S  I N  B C2 6ConclusionsThe current coverage regime for diabetes test strips offers an opportunity to reduce costs while main-taining consistency with existing clinical practice recommendations. The scale of the savings from such changes will be critically dependent on the restrictive-ness of the reimbursement policy. Further, BC should consider engaging in negotiations with manufactur-ers to achieve further savings through formulary price reductions for test strips. Implementing policy changes including both quantity limits and negotiated price reductions would likely result in more appropri-ate blood glucose testing and better value for money in the BC PharmaCare Program.UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CH2 7References1.  At the Tipping Point: Diabetes in British Columbia [Internet]. Canadian Diabetes Asso-ciation; 2013 [cited 2013 Apr 3]. Available from: http://www.diabetes.ca/documents/get-involved/17620_Diabetes_Prog_Report_BC_2.pdf2.  Public Health Agency of Canada. Diabetes in Canada: facts and figures from a public health perspective [Internet]. Ottawa: Public Health Agency of Canada; 2011. Available from: http://sfu.summon.serialssolutions.com/link/0/eLvHCXMwY2BQSAaWhqDF3cDKLtnY0C-w5MTHRzCzF0jAtBXzMTyLK4lik0txNlEHGzTXE2UMX2D2Lhw5fxCeB7r0zBtVFY-gy8iaBl33kl4O1hKQBULBsy3.  Canadian Diabetes Association Clinical Practice Guidelines Expert Committee. Canadian Diabetes Association 2013 Clinical PracticeGuidelines for the Prevention and Management of Diabetes in Canada [Internet]. Can J Diabetes; 2013 [cited 2013 Oct 19]. S1-S212 p. Available from: http://guidelines.diabetes.ca/App_Themes/CDACPG/resources/cpg_2013_full_en.pdf4.  Canadian Agency for Drugs and Technologies in Health. Optimal Therapy Recommen-dations for the Prescribing and Use of Blood Glucose Test Strips. Ottawa, ON: Canadian Agency for Drugs and Technologies in Health; 2009. 5.  COMPUS. Current Practice Analysis of Health Care Providers and Patients on Self-Monitor-ing of Blood Glucose [Internet]. COMPUS; 2009 Mar. Report No.: Vol 3, Issue 5. Available from: http://www.cadth.ca/media/pdf/compus_Current_Practice_Report_Vol-3-Issue-5.pdf6.  Malanda UL, Welschen LMC, Riphagen II, Dekker JM, Nijpels G, Bot SDM. Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin. Cochrane Database Syst Rev Online. 2012;1:CD005060. 7.  Farmer AJ, Perera R, Ward A, Heneghan C, Oke J, Barnett AH, et al. Meta-analysis of indi-vidual patient data in randomised trials of self monitoring of blood glucose in people with non-insulin treated type 2 diabetes. BMJ. 2012 Feb 27;344(feb27 1):e486–e486. 8.  Franciosi M, Pellegrini F, Berardis GD, Belfiglio M, Cavaliere D, Nardo BD, et al. The Impact of Blood Glucose Self-Monitoring on Metabolic Control and Quality of Life in Type 2 Diabetic Patients An urgent need for better educational strategies. Diabetes Care. 2001 Nov 1;24(11):1870–7. 9.  Peel E, Douglas M, Lawton J. Self Monitoring of Blood Glucose in Type 2 Diabetes: Longitu-dinal Qualitative Study of Patients’ Perspectives. BMJ. 2007;335(7618):493–6. 10.  Reimbursement and Pricing Policies - Sections 5.13 to 5.22 [Internet]. Pharmaceutical Ser-vices Division BC Ministry of Health; 1012 [cited 2013 Oct 21]. Available from: http://www.health.gov.bc.ca/pharmacare/pdf/5-13to5-22.pdf11.  PharmaCare Policy Manual, Sections 5.6 through 5.12: Reimbursement and Pricing Policies [Internet]. Pharmaceutical Services Division BC Ministry of Health; [cited 2013 Oct 21]. Available from: http://www.health.gov.bc.ca/pharmacare/pdf/5-6to5-12.pdfU T I L I Z A T I O N  PA T T E R N S  A N D  R E I M B U R S E M E N T  O P T I O N S  F O R  D I A B E T E S  T E S T  S T R I P S  I N  B C2 812.  BC PharmaCare Newsletter 12-005. BC Pharmacare Newsletter. 2012 Mar 30;12(005):1–7. 13.  Gomes T, Juurlink DN, Shah BR, Paterson JM, Mamdani MM. Blood glucose test strips: options to reduce usage. Can Med Assoc J. 2010 Jan 12;182(1):35–8. 14.  Self-Monitoring of Blood Glucose (SMBG) - Information for Patients and the Public - Medi-cation Matters [Internet]. [cited 2013 Oct 8]. Available from: http://www.medmatters.bc.ca/info-public/smbg.html15.  Shah BR, Gomes T, Juurlink DN, Paterson JM, Mamdani MM. Cost Minimal Effectiveness of SMBG. Can J DIABETES. 2010;34(3):180. 16.  Johnson JA, Majumdar SR, Bowker SL, Toth EL, Edwards A. Self-monitoring in Type 2 diabetes: a randomized trial of reimbursement policy. Diabet Med J Br Diabet Assoc. 2006;23(11):1247–51. 17.  COMPUS. Systematic Review of Use of Blood Glucose Test Strips for the Management of Diabetes Mellitus [Internet]. COMPUS; Report No.: Vol 3, Issue 2. Available from: http://www.cadth.ca/media/pdf/BGTS_SR_Report_of_Clinical_Outcomes.pdf18.  Cost-Effectiveness of Blood Glucose Test Strips in the Management of Adult Patients with Diabetes Mellitus [Internet]. Canadian Agency for Drugs and Technologies in Health; Avail-able from: http://www.cadth.ca/media/pdf/BGTS_Consolidated_Economic_Report.pdf19.  Gomes T, Juurlink DN, Shah BR, Peterson JM, Mamdani MM. Blood Glucose Test Strip Use: Patterns, Costs, and Potential Cost Reduction Associated with Reduced Testing [Inter-net]. Toronto, ON: ICES; 2009 Dec. Available from: http://www.ices.on.ca/file/Blood%20Glucose%20Test%20Strip_Dec2009.pdf20.  PMPRB. The Use of Blood Glucose Test Strips in Select Public Drug Plans, 2008. 2013. 21.  Self-Monitoring of Blood Glucose (SMBG) Recommendation Tool for Healthcare providers [Internet]. Canadian Diabetes Association; [cited 2013 Oct 21]. Available from: http://www.diabetes.ca/documents/for-professionals/SMBG_HCP_Tool_9.pdf22.  Post Market Review: Pharmaceutical Benefits Scheme Products Used in the Treatment of Diabetes [Internet]. Department of Health and Ageing; University of South Australia; 2012 Dec. Available from: http://www.pbs.gov.au/reviews/diabetes-files/blood-glucose-test-strips-draft-report.pdf23.  Polonsky WH, Fisher L. Self-Monitoring of Blood Glucose in Noninsulin-Using Type 2 Diabetic Patients: Right answer, but wrong question: self-monitoring of blood glucose can be clinically valuable for noninsulin users. Diabetes Care. 2013 Jan;36(1):179–82. 24.  Woo V. The Year in Review. Can J Diabetes. 2010;34(4):362–3. UBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CH2 925.  Miller D, Berard L, Cheng A, Hanna A, Hagerty D, Knip A, et al. Self-monitoring of blood glucose in people with type 2 diabetes: Canadian Diabetes Association briefing document for healthcare providers. Can J Diabetes [Internet]. 2011 Sep [cited 2013 Mar 26]; Available from: http://www.diabetes.ca/documents/for-professionals/CJD –Sept_2011 –SMBG.pdf26.  The SMBG International Working Group. Self-monitoring of blood glucose in type 2 diabe-tes: An inter-country comparison. Diabetes Res Clin Pract. 2008 Dec;82(3):e15–e18. 27.  Medicare’s Coverage of Diabetes Supplies and Services [Internet]. Centres for Medicare and Medicaid Services; [cited 2013 Oct 17]. Available from: http://www.medicare.gov/pubs/pdf/11022.pdf28.  New Zealand Pharmaceutical Schedule August 2013 [Internet]. Pharmac; 2013 [cited 2013 Oct 23]. Available from: http://www.pharmac.govt.nz/2013/07/30/Sched.pdf29.  Centers for Medicare and Medicaid Services. Fact Sheet: Expansion of competitive bidding program will increase competition, maintain quality, and save Medicare billions [Internet]. CMS.gov. 2013 [cited 2013 Apr 10]. Available from: https://www.cms.gov/apps/media/press/factsheet.asp?Counter=4513&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date30.  BC Ministry of Health. PharmaNet. V2. BC Ministry of Health. Data Extract. Data Steward-ship Committee (2013); 2013. Available from: http://www.popdata.bc.ca/data31.  Government of Canada HC. Non-Insured Health Benefits (NIHB) Program: A Guide for NIHB Clients on Blood Glucose Test Strips [Internet]. 2013 [cited 2014 Feb 24]. Available from: http://www.hc-sc.gc.ca/fniah-spnia/nihb-ssna/benefit-prestation/nihb-ssna-glucose-glycemie-eng.php32.  CBC News. N.S. government cancels diabetic cuts - Nova Scotia. 2010 Mar 3 [cited 2013 Mar 21]; Available from: http://www.cbc.ca/news/canada/nova-scotia/story/2010/03/03/ns-diabetic-cut-pharmacare-seniors.html33.  PHARMAC. Proposals relating to multiple diabetes management products [Internet]. 2012 [cited 2014 Mar 6]. Available from: http://www.pharmac.health.nz/assets/diabetes-blood-glucose-meters-proposal.pdf34.  PHARMAC. Diabetes management products proposal [Internet]. PHARMAC. [cited 2014 Mar 6]. Available from: http://www.pharmac.health.nz/medicines/your-health/diabetes/blood-glucose-meters-changes/diabetes-management-products-proposal/U T I L I Z A T I O N  PA T T E R N S  A N D  R E I M B U R S E M E N T  O P T I O N S  F O R  D I A B E T E S  T E S T  S T R I P S  I N  B C3 0Appendix 1: Oral Anti-Diabetic MedicationsTable 14. Pharmacotherapy treatments by risk of hypoglycemiaPharmacotherapy with a higher risk of hypoglycemiaSulfonylureas	(e.g.	acetohexamide,	chlorpropamide,	glibenclamide,	gliclazide,	glimepiride,	glyburide,	tolbutamide)Meglitinides	(e.g.	nateglinide,	repaglinide)Pharmacotherapy with a lower risk of hypoglycemiaMetforminAcarboseThiazolidinediones	(e.g.	pioglitazone,	rosiglitazone)DPP-4	inhibitors	(e.g.	saxagliptin,	sitagliptin)GLP-1	agonists	(e.g.	exenatide,	liraglutide)Adapted	from:	http://www.health.gov.on.ca/en/pro/programs/drugs/teststrips/docs/pro_faq.pdfUBC  C E N T R E  F O R  H E A LT H  S E R V I C E S  A ND  P O L I C Y  R E S E A R CH3 1Appendix 2: Test Strip Brand NamesTable 15. Test strip products eligible for coverageBC PIN Brand Name44123035 Sidekick	Bg	Test	Strip		44123036 True	Track	Bg	Test	Strip		44123041 Life	Brand	Portable	Blood	Glucose	Test	Strips		44123052 Medi+Sure	Blood	Glucose	Test	Strips		44123039 Life	Brand	Blood	Glucose	Test	Strips		44123023 Novo-Glucose	Bg	Test	Strip		44123045 Truetest	Blood	Glucose	Test	Strips		44123048 Rightest	Gs100	Blood	Glucose	Test	Strips		44123029 Prestige	Blood	Glucose	Test	Strips		44123054 Myglucohealth	Test	Strips		44123004 Glucofilm	Bg	Test	Strip		44123005 Glucostix	Bg	Test	Strip		44123034 Itest	Blood	Glucose	Test	Strip		44123018 Smart	Strip	Bg	Test	Strip		44123010 Tracer	Bg	Test	Strip	(Discontinued)		44123003 Encore	Bg	Test	Strip		44123047 Bgstar	Blood	Blood	Glucose	Test	Strips		44123013 Companion	Ii	Bg	Test	Strip	(Discontinued)		44123020 Chemstrip	Bg	Test	Strip	Visual	-	Discon-tinued		44123053 Freestyle	Precision	Blood	Glucose	Test	Strips		44123051 Bayer	Contour	Next	Blood	Glucose	Test	Strips		44123050 Novo	Nordisk	Blood	Glucose	Test	Strips		44123001 Dextrostix	Bg	Test	Strip	(Discontinued)		44123022 Checkmate	Plus	Bg	Test	Strip		44123007 Accu-Chek	Easy	Bg	Test	Strip	(Discon-tinued)		44123009 Chemstrip	Bg	Test	Strip	-	Discontinued		BC PIN Brand Name44123030 Bd	Blood	Glucose	Test	Strip		44123043 Nova	Max	Blood	Glucose	Test	Strips		44123044 Ez	Health	Oracle	Blood	Glucose	Test	Strips		44123011 One	Touch	Bg	Test	Strip		44123012 Surestep	Bg	Test	Strip		44123040 Freestyle	Lite	Blood	Glucose	Test	Strips		44123014 Exactech	Bg	Test	Strip	(Discontinued)		44123017 Fast	Take	Bg	Test	Strip		44123042 On-Call	Plus	Blood	Glucose	Test	Strips		44123024 Precision	Extra	Bg	Test	Strip		44123025 One	Touch	Ultra	Bg	Test	Strip		44123027 Sof-Tact	Blood	Glucose	Test	Strip		44123031 Precision	Easy	Bg	Test	Strip		44123049 Onetouch	Verio	Blood	Glucose	Test	Strips		44123028 Freestyle	Bg	Test	Strip		44123008 Advantage	Bg	Test	Strip	(Discontinued)		44123021 Advantage	Comfort	Bg	Test	Strip		44123037 Ascensia	Contour	Bg	Test	Strips		44123033 Accu-Chek	Aviva	Bg	Test	Strips		44123046 Accu-Chek	Mobile	Blood	Glucose	Test	Strip	44123026 Accu-Chek	Compact	Bg	Test	Strip		44123002 Ascensia	Elite	Bg	Test	Strip		44123019 Ascensia	Autodisc	Bg	Test	Strip		44123032 Ascensia	Microfill	Bg	Test	Strip		44123038 Ascensia	Breeze	2	Blood	Glucose	Test	Strips		44123015 Sensor	Electrodes	Plus	/	Precision	Bg	Test	Strip		44123016 Bg	Test	Strips	(Offline	Use	Only)		44123006 Accutrend	Bg	Test	Strip		UBC Centre for Health Services and Policy ResearchThe University of British Columbia201-2206 East MallVancouver, B.C. Canada V6T 1Z3Tel:  604.822.4969Fax:  604.822.5690Email: enquire@chspr.ubc.cawww.chspr.ubc.caAdvancing world-class health services and policy research and training on issues that matter to Canadians

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