What the HLTH 5479 is for
Some compounds are PharmaCare benefits when no suitable commercial product exists. Others are non-benefit compounds, and PharmaCare covers them only with Special Authority approval in place before dispensing. HLTH 5479 is that request. PharmaCare reviews each case and may approve full, partial or no coverage, and it doesn’t cover compounds containing non-benefit ingredients.
Who completes it
The prescriber completes and signs the form. The compounding pharmacy completes the Compound Costing Worksheet (HLTH 5425) and sends PharmaCare the pricing and prescription, and it must wait for approval before dispensing.
How to fill in the request
Sections 1 and 2, prescriber and patient information
Enter your name and mailing address, phone, fax, and college ID or MSP number. Tick Mail Confirmation if you want the reply by mail. Add the patient’s names, date of birth, date of application and PHN.
Section 3, compound information
Tick New Request or Renewal. Give the active ingredients, concentration and dosage form, and the dosage and regimen. Name the compounding pharmacy and its phone number so PharmaCare can contact it.
A, diagnosis
Give the diagnosis with details of severity.
B, all previously tried therapies and results
List every drug tried with dose, duration and outcome, and any pertinent non-drug therapy. This is the section that shows commercial alternatives have been exhausted, so an incomplete list weakens the whole request.
C, rationale for last resort compound use
Explain why the compound is needed for this patient: no commercial product at the dose, a formulation the patient can’t use, or an ingredient they can’t tolerate. Attach a separate sheet if you need more space.
Common reasons it’s sent back
- Commercial alternatives not tried or not listed in section B.
- No compounding pharmacy named, so PharmaCare can’t get the pricing.
- A compound intended to replace a short-supply product, with no shortage PIN in place.
- A compound containing a non-benefit ingredient.
- Missing severity in the diagnosis, or no rationale in section C.
- A missing signature.
Submitting and who pays
Fax the form to PharmaCare at 1-800-609-4884 or mail it to PharmaCare, Box 9652 Stn Prov Govt, Victoria, BC V8W 9P4. The compounding pharmacy sends its pricing and the prescription separately. If approved, PharmaCare covers the compound under the patient’s plan, including any deductible, and the pharmacy keeps the approved worksheet on file with the prescription.