What the HLTH 5481 is for
The form asks PharmaCare to cover a third-line oral agent for type 2 diabetes: linagliptin, saxagliptin, their metformin combinations, or pioglitazone. Each is a limited coverage drug, so the patient’s plan pays nothing until Special Authority is approved. Coverage starts on the date the approval is entered in PharmaNet and is not retroactive.
PharmaCare decides on one question: whether the patient’s glucose stayed inadequately controlled on maximally tolerated doses of metformin plus a sulfonylurea, or metformin plus an insulin. Semaglutide has its own form, the HLTH 5826, with a lower bar of metformin alone.
Who completes it
The prescriber completes every section and signs it. Pharmacists can submit Special Authority requests in specific circumstances, either as the prescriber or on a prescriber’s behalf. The patient has no part to fill in.
How to fill in the form
Section 1, Prescriber information, and Section 2, Patient information
Enter your name and mailing address, your College ID (the form says to use only the College ID number), and your fax number. PharmaCare marks the fax number critical for a timely response, and without a fax or mailing address it can’t return a decision. The patient’s PHN is marked critical for processing.
Section 3, Medication requested
Tick a DPP-4 inhibitor (linagliptin or saxagliptin, alone or with metformin) or pioglitazone. The form reminds you that a DPP-4 inhibitor isn’t covered alongside semaglutide. If the patient already has semaglutide approved, approving the DPP-4 inhibitor ends that coverage.
Section 4, Criteria for indefinite coverage
Tick option A (dual therapy of metformin and a sulfonylurea) or option B (dual therapy of metformin and an insulin). Both require inadequate control at maximally tolerated doses, so the chart should show the doses reached as well as the drug names. If the patient skipped one of those trials, use the rationale box to say why, for example a documented sulfonylurea hypoglycemia or a contraindication.
For pioglitazone, PharmaCare’s criteria note that it’s for combination treatment, not monotherapy, and that it’s contraindicated in NYHA class I to IV heart failure.
Signature
Sign the consent statement confirming you’ve told the patient why their information goes to PharmaCare. The signature is mandatory.
Common reasons it’s sent back
- Missing prescriber fax number or mailing address, so PharmaCare can’t reply.
- Missing PHN, or a number other than the College ID in the prescriber section.
- Neither option A nor B ticked, or a trial described without doses.
- A skipped trial with an empty rationale box.
- A DPP-4 inhibitor requested for a patient on approved semaglutide, without a plan to stop it.
Submitting and who pays
Submit through PharmaCare’s SA eForms, or fax the PDF to 1-800-609-4884 or mail it to PharmaCare, Box 9652 Stn Prov Govt, Victoria, BC V8W 9P4. PharmaCare says eForms are more secure and usually return decisions faster. Patients can track the request in Health Gateway.
PharmaCare doesn’t pay prescribers for the form. Approval covers the drug under the rules of the patient’s plan, so a Fair PharmaCare patient may still pay until they reach their deductible.