What the HLTH 5362 is for
Some COPD inhalers are PharmaCare regular benefits, such as tiotropium and umeclidinium. Others are limited coverage and need Special Authority. HLTH 5362 covers five classes, and the box at the top tells you which sections to complete: Sections 1, 2 and 3 for limited coverage LAMAs, 1, 2 and 4 for LABAs, 1, 2 and 5 for LAMA/LABA, 1, 2 and 6 for ICS/LABA, and 1, 2 and 7 for ICS/LAMA/LABA triple therapy.
Who completes it
The prescriber completes and signs the request. Respirologists are exempt for some of these inhalers, including umeclidinium-vilanterol.
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, and the patient’s names, date of birth, date of application and PHN.
Section 3, limited coverage LAMA inhalers
For aclidinium or glycopyrronium, the patient must have failed a trial of at least one month of each regular benefit LAMA: tiotropium and umeclidinium.
Section 4, LABA inhalers
For salmeterol, give the post-bronchodilator FEV1/FVC ratio (below 0.70), and describe the nature and severity of a contraindication or intolerance to LAMAs.
Sections 5 and 6, LAMA/LABA and ICS/LABA combinations
Both need moderate to very severe COPD with a post-bronchodilator FEV1/FVC below 0.70 and FEV1 below 80% predicted, and an inadequate response after at least six months of a LAMA or a LABA. Name the one tried. ICS/LABA also needs two or more moderate exacerbations in the past 12 months, treated with antibiotics or systemic steroids, or one severe exacerbation with an admission or emergency visit.
Section 7, triple therapy
For fluticasone furoate/umeclidinium/vilanterol or budesonide/glycopyrronium/formoterol, give the spirometry values, the LAMA/LABA or ICS/LABA product tried for at least six months, and the exacerbation history in the past 12 months. Use Section 8 for comments and sign in Section 9.
Common reasons it’s sent back
- Spirometry values missing, or pre-bronchodilator values given.
- An FEV1 percentage missing for the combination and triple sections.
- A trial shorter than six months, or no product named.
- Exacerbations described without the treatment or setting that defines moderate or severe.
- An asthma request submitted on this COPD form.
- Missing signature in Section 9.
Submitting and who pays
Submit through Special Authority eForms, or fax the form to PharmaCare at 1-800-609-4884. eForms can return a decision quickly, while faxed requests take about five weeks. Coverage starts when the approval is entered on PharmaNet and isn’t retroactive. The patient’s PharmaCare plan and deductible decide what they pay at the pharmacy.