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This version of the form is not currently in use and is provided for reference only. Download this version of
Form HLTH5495
for the current year.
Form HLTH5495 Special Authority Request - Adalimumab / Infliximab / Vedolizumab for Moderate to Severe Active Crohn's / Fistulizing Crohn's Disease - Renewal Coverage - British Columbia, Canada
Form HLTH5495 Special Authority Request - Adalimumab/Infliximab/Vedolizumab for Moderate to Severe Active Crohn's/Fistulizing Crohn's Disease - Renewal Coverage - British Columbia, Canada is used to request coverage for adalimumab, infliximab, or vedolizumab treatments for individuals with moderate to severe active Crohn's disease or fistulizing Crohn's disease in British Columbia, Canada. It is specifically for renewal coverage of these medications.
The form HLTH5495 Special Authority Request - Adalimumab/Infliximab/Vedolizumab for Moderate to Severe Active Crohn's/Fistulizing Crohn's Disease - Renewal Coverage in British Columbia, Canada, is usually filed by the prescribing physician or a healthcare provider in consultation with the patient.
FAQ
Q: What is the purpose of the HLTH5495 Special Authority Request?A: The HLTH5495 Special Authority Request is used to request coverage for medications such as Adalimumab, Infliximab, and Vedolizumab for the treatment of moderate to severe active Crohn's disease or fistulizing Crohn's disease.
Q: Who can use the HLTH5495 Special Authority Request?A: Residents of British Columbia, Canada who have been diagnosed with moderate to severe active Crohn's disease or fistulizing Crohn's disease may use the HLTH5495 Special Authority Request to request coverage for Adalimumab, Infliximab, or Vedolizumab.
Q: What medications can be requested through the HLTH5495 Special Authority Request?A: Adalimumab, Infliximab, and Vedolizumab can be requested through the HLTH5495 Special Authority Request for the treatment of moderate to severe active Crohn's disease or fistulizing Crohn's disease.
Q: What does the HLTH5495 Special Authority Request cover?A: The HLTH5495 Special Authority Request covers the cost of Adalimumab, Infliximab, or Vedolizumab for residents of British Columbia, Canada with moderate to severe active Crohn's disease or fistulizing Crohn's disease.
Q: How can I renew coverage through the HLTH5495 Special Authority Request?A: To renew coverage through the HLTH5495 Special Authority Request, you will need to fill out the renewal form and submit it to the appropriate authority in British Columbia, Canada.
Download Form HLTH5495 Special Authority Request - Adalimumab / Infliximab / Vedolizumab for Moderate to Severe Active Crohn's / Fistulizing Crohn's Disease - Renewal Coverage - British Columbia, Canada
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