What the HLTH 5493 is for
Evolocumab is a limited coverage drug in BC with two separate indications and two forms. HLTH 5493 covers heterozygous familial hypercholesterolemia in adults as an add-on to maximally tolerated statin therapy. Evolocumab after acute coronary syndrome has its own form, HLTH 5874, with a specialist requirement and a 52-week window.
For HeFH, PharmaCare checks three things: a definite or probable diagnosis, a recent lipid result above target, and three months of adherence to high-dose statin and ezetimibe or a documented reason they weren’t possible.
Who completes it
The prescriber completes and signs every section. PharmaCare lists no practitioner exemptions and no required specialty for the HeFH indication. 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 PHN. PharmaCare can’t return a decision without a fax number or mailing address. Page 2 repeats the patient’s name and PHN, so fill those in too.
Section 3, Medication coverage
The form names one regimen: evolocumab 140 mg subcutaneously every two weeks.
Section 4, Criteria for coverage, indefinite
Part A asks how the diagnosis was made: Simon Broome criteria, Dutch Lipid Network criteria, or genetic testing. Tick the one in the record.
Part B asks for the most recent LDL-C, non-HDL-C or ApoB with its value and lab date. The date must fall within the three months before evolocumab starts, so an older result means a repeat test before you submit. Medulla fills the value and its lab date from the results in the open chart, and leaves them blank if there’s no result.
Part C needs items 1 and 2 plus one of items 3 to 6. Item 1 is not reaching target: a reduction of at least 50% from untreated baseline for primary prevention, or LDL-C below 1.8 mmol/L, non-HDL-C below 2.4 mmol/L or ApoB below 0.7 g/L for secondary prevention. Item 2 is three months of ezetimibe, with details if the patient couldn’t finish the trial. Items 3 to 6 are three months of atorvastatin 80 mg or rosuvastatin 40 mg, intolerance to two statins (name each one), confirmed rhabdomyolysis, or a contraindication to statins.
Section 6, Additional comments, and signature
Use comments for anything that doesn’t fit Part C, such as a statin intolerance with creatine kinase results. Sign the consent statement. The signature is mandatory.
Common reasons it’s sent back
- A lipid result older than three months, or no lab date.
- No diagnostic method ticked in Part A.
- Ezetimibe trial shorter than three months with no intolerance described.
- Statin intolerance claimed without naming two statins and what happened.
- A post-ACS patient submitted on this form instead of HLTH 5874.
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. Coverage starts when the approval is entered in PharmaNet and is not retroactive.
PharmaCare doesn’t pay for the form. The patient’s plan rules, including any Fair PharmaCare deductible, apply to the drug.