What the HLTH 5395 is for
HLTH 5395 requests PharmaCare coverage of ticagrelor 90 mg twice daily, taken with ASA 75 to 150 mg daily, for acute coronary syndrome. A limited number of cardiologists, and selected internists working in a cardiology role, have collaborative prescribing agreements that cover their patients without a request. Prescriptions from anyone else aren’t covered automatically, which is when this form is needed.
Who completes it
The prescriber completes and signs the request. Cardiologists with a prescribing agreement must write ticagrelor prescriptions for the full intended duration of therapy.
How to fill in the request
Sections 1 and 2, prescriber and patient information
Enter your name and mailing address, phone, fax and your CPSBC or BCCNM licence number, not your MSP number. Tick Mail Confirmation if you want the decision by mail. Add the patient’s names, date of birth, date of application and PHN.
Section 3A, failure on clopidogrel and ASA
Choose this route when the patient was on optimal clopidogrel and ASA dual therapy and had one of: definite stent thrombosis after PCI, recurrent STEMI or NSTEMI after PCI, or recurrent unstable angina after PCI. Definite stent thrombosis must be confirmed by angiography or pathology, so cite the report.
Section 3B, PCI for acute coronary syndrome
Choose this route when the patient is undergoing PCI for STEMI, NSTEMI or unstable angina. Name the event and the PCI from the cardiology report.
Signature
The prescriber’s signature is mandatory, and confirms you’ve told the patient their information goes to PharmaCare.
Common reasons it’s sent back
- Neither route checked, or both.
- Stent thrombosis claimed without angiographic or pathologic confirmation.
- No PCI documented, since both routes depend on one.
- An MSP number instead of the college licence number.
- A request for more than 12 months of therapy.
Submitting and who pays
Submit through Special Authority eForms or fax the form to 1-800-609-4884. Coverage is valid from the date the approval is entered on PharmaNet, so a gap between the cardiology prescription running out and approval falls on the patient. Reimbursement follows the patient’s PharmaCare plan, including any deductible.