What the HLTH 5350 is for
The Reference Drug Program groups drugs in the same class and fully covers the lower-cost reference drugs, while others are partially covered. For PPIs, pantoprazole magnesium and rabeprazole are the reference drugs, and both are limited coverage, so even they need Special Authority. A patient who stays on a non-reference PPI without full coverage pays the difference.
Who completes it
The prescriber completes and signs the request. Gastroenterologists are exempt from submitting.
How to fill in the request
Sections 1 and 2, prescriber and patient information
Enter your name, mailing address, phone, fax and college ID only, then the patient’s names, date of birth, date of application and PHN. The fax number and PHN are flagged as critical.
Section 3, diagnosis for requested medication
Check one diagnosis: GERD, reflux esophagitis, duodenal ulcer, gastric ulcer, Barrett’s esophagus, Zollinger-Ellison syndrome, connective tissue disease such as lupus, scleroderma or CREST, H. pylori eradication as part of triple therapy, or other with a specified reason. H. pylori approvals are limited to 14 days.
Section 4, fully covered reference drugs
Use this section to request pantoprazole magnesium 40 mg or rabeprazole 10 or 20 mg.
Section 5, partially covered non-reference drugs
Use this section for esomeprazole, lansoprazole, omeprazole 20 mg or pantoprazole sodium 40 mg at full coverage. Enter the trial duration for rabeprazole and for pantoprazole magnesium. Full coverage needs a failed trial of at least four weeks of both at adequate doses, so one trial isn’t enough.
Section 6, compounded suspension
Request omeprazole or lansoprazole suspension with the dose and frequency when the patient can’t use any commercial product in Section 5, including opened capsules or water-dispersible and orally disintegrating forms. Tick whether the prescribed dose is commercially unavailable or give another reason.
Common reasons it’s sent back
- No diagnosis checked, or more than one medication section completed.
- A non-reference PPI requested with a trial of only one reference drug.
- Trial durations shorter than four weeks or left blank.
- A compounded suspension requested without explaining why commercial forms won’t work.
- Missing fax number, college ID or signature.
Submitting and who pays
Submit through Special Authority eForms or fax the form to 1-800-609-4884. Pantoprazole magnesium and rabeprazole requests are eligible for automatic approval when submitted online. Coverage begins when the approval is entered on PharmaNet. Reimbursement follows the patient’s PharmaCare plan, including any deductible.