What the HLTH 5492 is for
BC’s Reference Drug Program groups drugs that PharmaCare treats as equally safe and effective, and fully covers the cheaper reference drug in each group. ARBs and PPIs are the two classes where even the reference drugs need Special Authority. For ARBs, the gate is an intractable cough or angioedema on an ACE inhibitor.
The form covers two situations. A reference ARB (candesartan, losartan, telmisartan or valsartan) gets full coverage once the ACE inhibitor reaction is documented. A non-reference ARB (olmesartan or irbesartan) gets partial coverage on the same reaction, and full coverage only when every reference ARB has failed or wasn’t tolerated.
Who completes it
The prescriber completes and signs it. The banner at the top of the form tells you which sections to fill in: Sections 1 to 3 for a reference ARB, and Sections 1, 2 and 4A, plus 4B if you want full coverage, for a non-reference ARB. 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, mailing address, College ID and fax number, and the patient’s name, date of birth and PHN. PharmaCare can’t return a decision without a fax number or mailing address.
Section 3, Reference ARBs (full coverage)
Confirm the intractable cough or angioedema on an ACE inhibitor and select one drug: candesartan, losartan, telmisartan or valsartan. The chart note should name the ACE inhibitor and the reaction. A mild cough that settled isn’t what the criterion describes.
Section 4A and 4B, Non-reference ARBs
In 4A, confirm the same ACE inhibitor reaction and choose olmesartan or irbesartan. That alone gives partial coverage, capped at the daily cost of a reference ARB, and the patient pays the difference.
For full coverage, complete 4B. The table has a column for each reference ARB. For each one, mark whether it was discontinued for failure or intolerance and give approximate trial dates. All four must be filled in. PharmaCare’s criteria ask for failure on optimal doses, so a short trial at a starting dose is weak evidence.
Section 5, Additional comments, and Section 6, Prescriber signature
Use comments for anything the table can’t hold, such as the specific intolerance. Sign the consent statement. The signature is mandatory.
Common reasons it’s sent back
- Wrong sections completed for the drug requested.
- No ACE inhibitor reaction documented, or a reaction other than cough or angioedema.
- Full coverage requested for olmesartan or irbesartan with fewer than four reference ARBs in the 4B table.
- Trial dates or the reason for stopping left blank.
- A formulation that isn’t a PharmaCare benefit, such as candesartan 4 mg.
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’s candesartan criteria page notes that an eForm request for it can be approved automatically when the patient meets the criteria.
PharmaCare doesn’t pay for the form. Fair PharmaCare patients still meet their deductible before PharmaCare pays for reference drugs.