What the HLTH 5825 is for
Icosapent ethyl is a limited coverage drug in BC. The form asks PharmaCare to cover it with a statin to reduce cardiovascular risk in patients who already have cardiovascular disease. Every criterion in Section 4 must be met, and two of them are lab results with dates, so a missing lab date or an out-of-range value is enough to stop the request.
Coverage starts when the approval is entered in PharmaNet and isn’t retroactive.
Who completes it
The prescriber completes and signs it. PharmaCare lists no practitioner exemptions. 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 coverage
The form names icosapent ethyl 1 g capsules, up to 4 g daily.
Section 4, Criteria for initial coverage, indefinite
Tick A for age 45 or older and B for established cardiovascular disease requiring secondary prevention. Tick C for maximally tolerated statin therapy for at least four weeks, aimed at an LDL-C below 1.8 mmol/L.
D and E need numbers. D is a fasting triglyceride between 1.70 and 5.59 mmol/L, and E an LDL-C between 1.01 and 2.59 mmol/L, each with its lab date and each measured within the three months before treatment starts. A non-fasting triglyceride, or a result from four months ago, won’t do. If triglycerides are too high for LDL-C to be calculated, tick that box under E instead. Medulla fills both values and their dates from the open chart’s results and leaves them blank when there’s no recent result.
Section 6, Additional comments, and signature
Use comments for context PharmaCare can’t see, such as the cardiovascular event and its date, or why the statin dose is the maximum tolerated. Sign the consent statement. The signature is mandatory.
Common reasons it’s sent back
- A triglyceride or LDL-C result without its lab date.
- A lab result older than three months before the start of treatment.
- A triglyceride above 5.59 or LDL-C outside 1.01 to 2.59 mmol/L.
- A primary prevention patient with risk factors but no established disease.
- Statin therapy shorter than four weeks.
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 Special Authority page currently gives about five weeks for regular requests, and says eForms are usually quicker.
PharmaCare doesn’t pay for the form. The drug is covered under the patient’s plan rules, including any Fair PharmaCare deductible.