What the HLTH 5484 is for
Sacubitril-valsartan is a limited coverage drug in BC. The form asks PharmaCare to cover it for heart failure with reduced ejection fraction in NYHA class II or III patients whose symptoms persist on standard therapy. PharmaCare checks the ejection fraction, the symptom class and whether the patient spent at least four weeks at a stable, optimum dose of both a beta-blocker and an ACE inhibitor or ARB.
Coverage starts when the approval is entered in PharmaNet. It is not retroactive, so PharmaCare suggests the patient fill only after approval, or use a partial fill.
Who completes it
The prescriber completes and signs every section. The patient has no part to fill in.
How to fill in the form
Section 1, Prescriber’s information, and Section 2, Patient information
Give your name, mailing address, College ID and fax number. PharmaCare can’t reply without a fax number or mailing address. The PHN is marked critical for processing.
Section 3, Medication requested
The form lists all three strengths, 24 mg/26 mg, 49 mg/51 mg and 97 mg/103 mg, under a single drug code, so there is no strength to pick.
Section 4, Criteria for indefinite coverage
All criteria must be met and marked. Tick the beta-blocker and the ACE inhibitor or ARB, then write the name of the ACE inhibitor or ARB trialed and the trial’s duration. The form states a minimum of four weeks, so give dates rather than “several months”.
Confirm the patient will use sacubitril-valsartan with other recommended therapies, including an aldosterone antagonist if tolerated. Enter the LVEF. The form’s blank is labelled below 40%, so a value of exactly 40% is worth checking against the criteria page before you submit.
The section ends with a reminder that sacubitril-valsartan replaces the ACE inhibitor or ARB. Make sure the medication list you send matches.
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
- No LVEF, or an LVEF above 40%.
- The ACE inhibitor or ARB named without a trial duration, or a trial shorter than four weeks.
- No beta-blocker trial ticked.
- NYHA class I or IV symptoms, which fall outside the criteria.
- Missing fax number, mailing address or PHN.
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 may use PharmaNet records to check the prior trials you describe.
PharmaCare doesn’t pay for the form. The patient’s plan rules, including any Fair PharmaCare deductible, apply to the approved drug.