Limited coverage criteria – oseltamivir

 

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Practitioner exemptions

• None

Special notes

• ¹Patients at high risk of complications from influenza are defined as follows:
  • Adults ≥ 65 years of age, with or without chronic health conditions
  • Individuals less than 65 years of age (including children and adolescents) with the following health conditions:
    • cardiac disorders
    • pulmonary disorders (e.g., chronic obstructive pulmonary disease, bronchopulmonary dysplasia, cystic fibrosis, asthma, home ventilation/tracheostomy)
    • diabetes and other metabolic diseases
    • cancer, immunodeficiency (including human immunodeficiency virus [HIV] infection), immunosuppression due to underlying disease or therapy (e.g., severe rheumatoid arthritis requiring immunosuppressive therapies, transplant)
    • chronic kidney disease
    • chronic liver disease, including hepatitis C
    • anemia and hemoglobinopathy
    • conditions that compromise the management of respiratory secretions and are associated with an increased risk of aspiration (e.g., cognitive dysfunction, spinal cord injury, seizure disorder, and neuromuscular disorders)
  • Individuals up to 18 years with conditions treated for long periods with acetylsalicylic acid
    Individuals who are morbidly obese (BMI ≥ 40) BMI >3 Z-scores above the mean for age and gender
  • Healthy children up to 59 months old
  • Children and adolescents up to 18 years old residing in remote communities, communal settings or chronic care facilities
  • Pregnant women
  • ​Indigenous people living on or off reserve
• ²Due to the risk of inappropriate utilization leading to antiviral resistance, clinicians are advised to be selective and judicious in their assessment of patients. Clinicians are advised to check the BC Centre for Disease Control influenza bulletin (updated regularly) at http://www.bccdc.ca/health-professionals/data-reports/communicable-diseases/influenza-surveillance-reports for the most recent information on circulating influenza strains and resistance patterns
• ³PharmaCare coverage is intended for antiviral treatment that is initiated within 48 hours of influenza symptom onset in the community setting. Evidence suggests that early treatment leads to optimal outcomes (Treanor JJ et al., JAMA 2000; 283: 1016-1024 and Nicholson KG et al. Lancet 2000; 355: 1845-1850)
• Prescribers do not need to submit a Special Authority request for this coverage. Patients who do not meet the limited coverage criteria are not eligible for PharmaCare coverage of the prescription. Patients requesting a “pre-fill” prescription for oseltamivir or zanamivir are responsible for the cost. When writing a prescription for patients who do not meet the criteria, physicians should write “Submit as zero cost to PharmaCare” on prescriptions. When submitting a claim for a prescription with this note, pharmacists should use the intervention code DE Adjudicate to $0.00 as requested. This ensures appropriate PharmaCare coverage
• PharmaCare coverage is not intended for patients who do not have symptoms of Influenza A or B nor for post-exposure prophylaxis
• Influenza immunization is one of the most effective methods for preventing influenza infection and its complications and should be promoted to the entire population whenever possible. Patients at high risk for complications from influenza should be immunized annually
   

Special Authority request form(s)

• Not applicable