What the HLTH 5398 is for
PharmaCare limits the number of blood glucose test strips it covers each calendar year, and the limit depends on the patient’s treatment: 200 for diet and lifestyle alone or lower-risk drugs, 400 for drugs with a higher hypoglycemia risk, 200 for insulin users with a CGM or flash monitor, and 3,000 for insulin users without one. HLTH 5398 requests coverage above that limit, up to 100 additional strips a year. It’s for patients with diabetes who aren’t on insulin, and for insulin users who wear a glucose monitoring system and still need fingerstick strips.
Who completes it
A prescriber or a diabetes education centre completes the request. The signature line reads Clinician’s Signature and is mandatory.
How to fill in the request
Section 1, prescriber or diabetes education centre
Enter the name and mailing address, phone and fax, and either your college ID or the centre’s PharmaCare DEC code. The fax number is the field PharmaCare needs to send the decision back.
Section 2, patient information
Enter the patient’s names, date of birth, date of application and PHN.
Section 3, blood glucose test strip criteria
Confirm the patient has diabetes and either isn’t on insulin, or is on insulin and using a glucose monitoring system. Then check at least one reason: glycemic targets not met for three months or more, acute illness or comorbidities affecting glucose control, drug therapy changes that may affect glucose control, an occupation where hypoglycemia is a significant safety risk such as pilot, air traffic controller or commercial driver, or gestational diabetes. Name the specific medication change or illness in the chart so the reason is concrete.
Common reasons it’s sent back
- An insulin user who doesn’t use a glucose monitoring system.
- No qualifying reason checked.
- No college ID or DEC code in Section 1.
- A missing fax number, so the decision can’t be returned.
- An unsigned form.
Submitting and who pays
Submit through Special Authority eForms or fax the form to 1-800-609-4884. Approvals through this form are limited to 100 additional strips per calendar year. For patients on insulin who need more, PharmaCare considers a written request from an endocrinologist case by case. The patient’s PharmaCare plan and deductible still apply to the extra strips.