What the HLTH 5824 is for
The form asks PharmaCare to cover one product: the inhaler combining 160 mcg mometasone furoate, 150 mcg indacaterol and 50 mcg glycopyrronium. It’s a limited coverage drug for asthma, and PharmaCare checks three criteria, all required: a diagnosis of asthma, an inadequate response to a LABA with a moderate to high dose inhaled corticosteroid, and at least one exacerbation in the past 12 months.
It’s often confused with the COPD inhaler request, HLTH 5362, which has different criteria. Make sure the diagnosis in the chart is asthma before you use this one.
Who completes it
The prescriber completes and signs it. Respirologists and allergists can apply for an individual exemption, and with one their prescriptions are covered without the form. 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 reply without a fax number or mailing address.
Section 3, Medication requested
There’s one product on the form, so nothing to choose.
Section 4, Criteria for indefinite coverage
Tick A for the asthma diagnosis. Tick B for an inadequate response on an optimal dose of a LABA, such as salmeterol, formoterol or vilanterol, together with a moderate to high dose inhaled corticosteroid, such as fluticasone, budesonide or mometasone. A low-dose inhaled corticosteroid doesn’t meet B, so the chart should show the dose.
Tick C for one or more exacerbations in the previous 12 months. The form defines a clinically significant exacerbation as one needing systemic corticosteroids (IV, or oral for at least three days), an emergency visit or a hospitalization. Use the Additional information box to give the date and what happened.
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
- A COPD patient submitted on the asthma form.
- An inhaled corticosteroid dose that isn’t moderate to high.
- No exacerbation in the past 12 months, or one treated with oral steroids for fewer than three days.
- An exacerbation ticked with no date or details.
- 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. Coverage starts when the approval is entered in PharmaNet and isn’t retroactive.
PharmaCare doesn’t pay for the form. The inhaler is covered under the patient’s plan rules, including any Fair PharmaCare deductible.