What the HLTH 5817 is for
Continuous and flash glucose monitors are limited coverage benefits in BC. This form asks PharmaCare to cover a Dexcom G6 or G7, or a FreeStyle Libre 2 or 3 Plus, for a person with diabetes on intensive insulin therapy. PharmaCare decides on three things: the device and the patient’s age, the insulin regimen, and education plus at least one qualifying risk.
The form has two paths. Initial coverage lasts three years and uses Sections 1 to 3. Renewal lasts five years and uses Sections 1, 2 and 4. Tick the right box at the top of the form.
Who completes it
The prescriber completes and signs it. PharmaCare lists no practitioner exemptions, so a diabetes specialist submits a request like anyone else. The patient has no part to fill in, though Section 3 asks you to confirm the patient, family or caregiver agrees to diabetes education.
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 reply without a fax number or mailing address. Page 2 repeats the patient’s name and PHN.
Section 3, Initial coverage (3 years)
All three items must apply and be ticked. Item 1 is the device: Dexcom for patients 2 or older, FreeStyle Libre 3 Plus for 2 or older, or Libre 2 for 4 or older. Item 2 is insulin pump therapy, or multiple daily injections with the number of basal and bolus injections written in. The definition is at least one basal and three bolus, four or more a day, so a patient on two premixed injections doesn’t qualify.
Item 3 is the commitment to comprehensive diabetes education by an interdisciplinary team and regular follow-up, plus at least one of: hypoglycemia unawareness, frequent and unpredictable hypoglycemia, unpredictable glucose swings, a functional restriction that prevents strip testing, or an occupation where hypoglycemia is a safety risk. Page 2 defines the first three. Frequent means more than three episodes a week, and swings mean readings below 4 or above 10 mmol/L without a predictable cause. Your note should carry those numbers.
Section 4, Coverage renewal (5 years)
Select the device, confirm the patient still uses a pump or multiple daily injections (with counts), and confirm they’ll benefit from continued use. Renewal doesn’t ask you to repeat the hypoglycemia criteria.
Test strips and signature
Both sections end with the 200-strip annual limit for CGM and flash monitor users. Tick the Nursing Support Services box only for a child under that program who needs more strips. Sign on page 2. The signature is mandatory.
Common reasons it’s sent back
- Multiple daily injections ticked without basal and bolus counts.
- An insulin regimen below four injections a day.
- No qualifying risk ticked, or hypoglycemia described without frequency.
- The initial and renewal sections mixed up.
- A device the patient is too young for, such as Libre 2 under age 4.
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 isn’t retroactive.
PharmaCare doesn’t pay for the form. Coverage follows the patient’s plan rules, including any Fair PharmaCare deductible. Patients with private insurance may need their insurer’s own form, such as Pacific Blue Cross’s CGM request.