What the HLTH 5822 is for
Atogepant, eptinezumab, fremanezumab and galcanezumab are limited coverage drugs for migraine prevention in BC, and this one form covers all four. The fremanezumab criteria are for adults 18 and older. PharmaCare decides on three things at the start: a confirmed diagnosis of episodic or chronic migraine, a baseline count of migraine days, and an inadequate response or intolerance to two oral preventives from different classes.
The form has three paths, chosen by a box at the top. Initial requests use Sections 1 to 4, a switch to another CGRP antagonist uses Sections 1 to 3 and 5, and renewals use Sections 1 to 3 and 6.
Who completes it
The prescriber completes and signs it. Each path asks you to confirm you have appropriate experience managing migraine. PharmaCare lists no practitioner exemptions. The patient doesn’t fill in the form, but the baseline comes from the migraine journal or app they keep, so ask them to start one three months before you plan to apply.
How to fill in the form
Section 3, Medication requested
Pick one drug and its regimen. The form prints each dose: atogepant 10, 30 or 60 mg daily (60 mg for chronic migraine), eptinezumab 100 or 300 mg IV every 12 weeks, fremanezumab 225 mg monthly or 675 mg every three months, and galcanezumab 240 mg loading then 120 mg monthly.
Section 4, Criteria for initial coverage (6 months)
In A, tick episodic migraine (at least 4 migraine days and fewer than 15 headache days a month for more than three months) or chronic migraine (at least 8 migraine days and at least 15 headache days a month for more than three months).
In B, give the average migraine days per month over the three months before the request, with the month it was calculated. PharmaCare rejects ranges, less-than or greater-than signs, and headache days in place of migraine days. This number becomes the fixed baseline for every renewal.
In C, list at least two oral preventives from two classes, with daily dose, trial duration, and whether each was stopped for inadequate response (after at least three months at optimal dose) or intolerance, with details.
Section 5, Switching to another CGRP antagonist (6 months)
Give the name and dose of the CGRP antagonist being stopped, the date it stopped, and why: failure to achieve or to maintain a 50% reduction from baseline, or another reason. Add a current three-month average.
Section 6, Criteria for renewal
Confirm the patient reached and kept at least a 50% reduction in average migraine days compared with baseline, and give the current average and the month it was calculated. Tick first renewal (6 months) or second and later (1 year). Sign on page 2. The signature is mandatory.
Common reasons it’s sent back
- A baseline written as a range, such as “10 to 12”, or as headache days.
- Two prior drugs from the same class, or an injectable or acute treatment listed.
- A prior trial under three months with no intolerance described.
- A renewal with less than a 50% reduction from the original baseline.
- The wrong path ticked for the request.
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 approval is entered in PharmaNet and isn’t retroactive, so plan renewals before the current approval ends.
PharmaCare doesn’t pay for the form. The drug is covered under the patient’s plan rules, including any Fair PharmaCare deductible.