This one-page form, part of BC PharmaCare's Reference Drug Program, is how a prescriber requests Special Authority coverage of a proton pump inhibitor. The prescriber checks the diagnosis, such as GERD, a peptic ulcer, Barrett's esophagus or H. pylori eradication, then requests a fully covered reference PPI, full coverage of a partially covered PPI after failed trials, or a compounded suspension.
The prescriber completes sections 1 to 3 and one of sections 4, 5 or 6, then signs to confirm the patient was told why their information is released to PharmaCare.
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Proton Pump Inhibitors (PPIs) (Special Authority request)
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The form lists pantoprazole magnesium 40 mg tablets and rabeprazole 10 mg and 20 mg tablets as the fully covered reference drugs in section 4. Esomeprazole, lansoprazole, omeprazole and pantoprazole sodium are partially covered non-reference drugs, requested in section 5.
Complete section 5, giving the trial durations for rabeprazole and pantoprazole magnesium. The form grants full coverage status for a partially covered PPI only after the patient has failed trials of at least 4 weeks of both reference drugs at adequate doses.
Section 3 lists GERD, reflux esophagitis, duodenal ulcer, gastric ulcer, Barrett's esophagus, Zollinger-Ellison syndrome, connective tissue disease such as lupus, scleroderma or CREST, and H. pylori eradication as part of triple therapy, plus an 'other' option that must be specified.