Form HLTH5465 "Special Authority Request - Donepezil, Galantamine and Rivastigmine" - British Columbia, Canada

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Download Form HLTH5465 "Special Authority Request - Donepezil, Galantamine and Rivastigmine" - British Columbia, Canada

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SPECIAL AUTHORITY REQUEST
DONEPEZIL, GALANTAMINE AND RIVASTIGMINE
HLTH 5465 Rev. 2018/12/03
For up to date criteria and forms, please check: www.gov.bc.ca/pharmacarespecialauthority
Fax requests to 1 800 609-4884 (toll free) OR mail requests to: PharmaCare, Box 9652 Stn Prov Govt, Victoria, BC V8W 9P4
This facsimile is Doctor-Patient privileged and contains confidential information intended only for PharmaCare. Any other distribution, copying or disclosure is strictly prohibited. If you have
received this fax in error, please write “MIS-DIRECTED” across the front of the form and fax toll-free to 1 800 609-4884, then destroy the pages received in error.
If PharmaCare approves this Special Authority request, approval is granted solely for the purpose of covering prescription costs. PharmaCare approval does not indicate that the requested
medication is, or is not, suitable for any specific patient or condition.
Forms with information missing will be returned for completion. If no prescriber fax or mailing address is provided, PharmaCare will be unable to return a response.
SECTION 1 – PRESCRIBER INFORMATION
SECTION 2 – PATIENT INFORMATION
NAME AND MAILING ADDRESS
PATIENT (FAMILY) NAME
MAIL CONFIRMATION
PATIENT (GIVEN) NAME(S)
PHONE NUMBER (INCLUDE AREA CODE)
DATE OF BIRTH (YYYY / MM / DD)
DATE OF APPLICATION (YYYY / MM / DD)
COLLEGE ID OR
MSP NUMBER
PRESCRIBER’S FAX NUMBER
PERSONAL HEALTH NUMBER (PHN)
CRITICAL FOR A
CRITICAL FOR
TIMELY RESPONSE
PROCESSING
SECTION 3 – MEDICATION DETAIL INFORMATION
INITIAL: Donepezil (must be tried before Galantamine or Rivastigmine) Initial coverage is for 6 months.
Required range for all requests: Standardized Mini-Mental State Score (SMMSE): >10 to <26; Global Deterioration Scale (GDS) stage: >4 to <6.
9901-0087
DONEPEZIL:
(5 mg to 10 mg daily); initial request requires a diagnosis of mild-moderate Alzheimer’s disease with or without Parkinsonian features (Lewy bodies), vascular
component or mixed dementia diagnosis
Unable to complete SMMSE because of functional illiteracy
SWITCHING: Galantamine or Rivastigmine (switching due to intolerance only) Initial coverage is for 6 months.
• Switching due to ineffectiveness is not eligible for coverage because there is limited evidence that another product will provide added benefit.
• Required range for all requests: Standardized Mini-Mental State Score (SMMSE): >10 to <26; Global Deterioration Scale (GDS) stage: >4 to <6.
• Donepezil must have been tried prior to request for Galantamine or Rivastigmine.
9901-0085
9901-0086
GALANTAMINE:
RIVASTIGMINE ORAL TABLETS:
(16 mg to 24 mg daily): switch from Donepezil or Rivastigmine
(6 mg to 12 mg daily): switch from Donepezil or Galantamine
Intolerance Details Required - please list nature and severity of intolerance
RENEWAL: Donepezil, Galantamine or Rivastigmine
Renewal is for one year for first renewal, and consideration for indefinite coverage on second renewal.
Required range for all requests: Standardized Mini-Mental State Score (SMMSE): >10 to <26; Global Deterioration Scale (GDS) stage: >4 to <6.
9901-0087
9901-0085
DONEPEZIL:
GALANTAMINE:
(5 mg to 10 mg daily)
(16 mg to 24 mg daily)
9901-0086
RIVASTIGMINE ORAL TABLETS:
(6 mg to 12 mg daily)
I have discussed with the patient that the purpose of releasing their
Personal information on this form is collected, used and disclosed under the authority of,
and in accordance with, the British Columbia Pharmaceutical Services Act and Freedom of
information to PharmaCare is to obtain Special Authority for prescription
Information and Protection of Privacy Act. It will not be disclosed to any persons without
coverage and for the purposes set out here.
the patient’s consent.The information you provide will be relevant to and used solely to (a)
provide PharmaCare benefits for the medication requested, (b) to implement, monitor and
evaluate this and other Ministry programs, and (c) to manage and plan for the health system
generally. If you have any questions about the collection or use of this information,
call Health Insurance BC from Vancouver at 1-604-683-7151 or from elsewhere in BC toll free at
1-800-663-7100 and ask to consult a pharmacist concerning the Special Authority process.
Prescriber’s Signature (Mandatory)
PharmaCare may request additional documentation to support this Special Authority request.
Actual reimbursement is subject to the rules of a patient's PharmaCare plan, including any annual deductible requirement, and to any other applicable PharmaCare pricing policy.
PHARMACARE USE ONLY
STATUS
EFFECTIVE DATE (YYYY / MM / DD)
DURATION OF APPROVAL
PRINT
CLEAR FORM
SPECIAL AUTHORITY REQUEST
DONEPEZIL, GALANTAMINE AND RIVASTIGMINE
HLTH 5465 Rev. 2018/12/03
For up to date criteria and forms, please check: www.gov.bc.ca/pharmacarespecialauthority
Fax requests to 1 800 609-4884 (toll free) OR mail requests to: PharmaCare, Box 9652 Stn Prov Govt, Victoria, BC V8W 9P4
This facsimile is Doctor-Patient privileged and contains confidential information intended only for PharmaCare. Any other distribution, copying or disclosure is strictly prohibited. If you have
received this fax in error, please write “MIS-DIRECTED” across the front of the form and fax toll-free to 1 800 609-4884, then destroy the pages received in error.
If PharmaCare approves this Special Authority request, approval is granted solely for the purpose of covering prescription costs. PharmaCare approval does not indicate that the requested
medication is, or is not, suitable for any specific patient or condition.
Forms with information missing will be returned for completion. If no prescriber fax or mailing address is provided, PharmaCare will be unable to return a response.
SECTION 1 – PRESCRIBER INFORMATION
SECTION 2 – PATIENT INFORMATION
NAME AND MAILING ADDRESS
PATIENT (FAMILY) NAME
MAIL CONFIRMATION
PATIENT (GIVEN) NAME(S)
PHONE NUMBER (INCLUDE AREA CODE)
DATE OF BIRTH (YYYY / MM / DD)
DATE OF APPLICATION (YYYY / MM / DD)
COLLEGE ID OR
MSP NUMBER
PRESCRIBER’S FAX NUMBER
PERSONAL HEALTH NUMBER (PHN)
CRITICAL FOR A
CRITICAL FOR
TIMELY RESPONSE
PROCESSING
SECTION 3 – MEDICATION DETAIL INFORMATION
INITIAL: Donepezil (must be tried before Galantamine or Rivastigmine) Initial coverage is for 6 months.
Required range for all requests: Standardized Mini-Mental State Score (SMMSE): >10 to <26; Global Deterioration Scale (GDS) stage: >4 to <6.
9901-0087
DONEPEZIL:
(5 mg to 10 mg daily); initial request requires a diagnosis of mild-moderate Alzheimer’s disease with or without Parkinsonian features (Lewy bodies), vascular
component or mixed dementia diagnosis
Unable to complete SMMSE because of functional illiteracy
SWITCHING: Galantamine or Rivastigmine (switching due to intolerance only) Initial coverage is for 6 months.
• Switching due to ineffectiveness is not eligible for coverage because there is limited evidence that another product will provide added benefit.
• Required range for all requests: Standardized Mini-Mental State Score (SMMSE): >10 to <26; Global Deterioration Scale (GDS) stage: >4 to <6.
• Donepezil must have been tried prior to request for Galantamine or Rivastigmine.
9901-0085
9901-0086
GALANTAMINE:
RIVASTIGMINE ORAL TABLETS:
(16 mg to 24 mg daily): switch from Donepezil or Rivastigmine
(6 mg to 12 mg daily): switch from Donepezil or Galantamine
Intolerance Details Required - please list nature and severity of intolerance
RENEWAL: Donepezil, Galantamine or Rivastigmine
Renewal is for one year for first renewal, and consideration for indefinite coverage on second renewal.
Required range for all requests: Standardized Mini-Mental State Score (SMMSE): >10 to <26; Global Deterioration Scale (GDS) stage: >4 to <6.
9901-0087
9901-0085
DONEPEZIL:
GALANTAMINE:
(5 mg to 10 mg daily)
(16 mg to 24 mg daily)
9901-0086
RIVASTIGMINE ORAL TABLETS:
(6 mg to 12 mg daily)
I have discussed with the patient that the purpose of releasing their
Personal information on this form is collected, used and disclosed under the authority of,
and in accordance with, the British Columbia Pharmaceutical Services Act and Freedom of
information to PharmaCare is to obtain Special Authority for prescription
Information and Protection of Privacy Act. It will not be disclosed to any persons without
coverage and for the purposes set out here.
the patient’s consent.The information you provide will be relevant to and used solely to (a)
provide PharmaCare benefits for the medication requested, (b) to implement, monitor and
evaluate this and other Ministry programs, and (c) to manage and plan for the health system
generally. If you have any questions about the collection or use of this information,
call Health Insurance BC from Vancouver at 1-604-683-7151 or from elsewhere in BC toll free at
1-800-663-7100 and ask to consult a pharmacist concerning the Special Authority process.
Prescriber’s Signature (Mandatory)
PharmaCare may request additional documentation to support this Special Authority request.
Actual reimbursement is subject to the rules of a patient's PharmaCare plan, including any annual deductible requirement, and to any other applicable PharmaCare pricing policy.
PHARMACARE USE ONLY
STATUS
EFFECTIVE DATE (YYYY / MM / DD)
DURATION OF APPROVAL
PRINT
CLEAR FORM