What the HLTH 5472 is for
HLTH 5472 requests PharmaCare coverage of long-acting ADHD medication: methylphenidate ER, methylphenidate CR, mixed amphetamine salts ER, lisdexamfetamine, or atomoxetine. PharmaCare covers these when shorter-acting stimulants haven’t worked or weren’t tolerated. Its criteria page says coverage isn’t intended for performance enhancement in people without symptoms or functional impairment.
Who completes it
The prescriber completes and signs the request. PharmaCare lists no practitioner exemptions, so psychiatrists and pediatricians submit it too.
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, requested medication
Check the product: methylphenidate ER (Concerta and generics), methylphenidate CR (Foquest), mixed amphetamine salts ER (generics of Adderall), lisdexamfetamine (Vyvanse and generics), or atomoxetine (generics of Strattera).
Section 4, diagnosis
Confirm the patient is six or older, has been diagnosed with ADHD, and needs 12 hours of continuous coverage for hyperactivity, impulsivity or inattention that interferes with functioning. This box is required for every drug.
Section 5, previous therapy trials
For a long-acting stimulant, document a trial of Ritalin-type methylphenidate or Dexedrine-type dextroamphetamine at an adequate dose for at least one week. For atomoxetine, document trials of both methylphenidate and an amphetamine, with at least one long-acting product. Give the product, dose and duration of each, and the result. If the patient couldn’t complete the trials, explain why on the last line.
Common reasons it’s sent back
- A trial listed without its dose, duration or result.
- A trial shorter than one week.
- Atomoxetine requested after only one stimulant class.
- A patient under six.
- No mention of the need for 12 hours of continuous coverage.
- 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. Coverage starts on the date the approval is entered on PharmaNet and isn’t retroactive, so the patient should wait for approval before filling the long-acting prescription. Reimbursement follows the patient’s PharmaCare plan, including any deductible.