What the HLTH 5338 is for
PharmaCare lists dalteparin, biosimilar enoxaparin, nadroparin and tinzaparin as limited coverage drugs. HLTH 5338 requests coverage for outpatient use in two groups: treatment of venous thromboembolism, and prophylaxis after surgery or in high-risk situations. Cancer-associated thrombosis has a separate form, HLTH 5469, with a longer approval.
Approval covers only the balance of the total duration of therapy for outpatients. Doses given post-operatively in hospital count toward that total.
Who completes it
The prescriber completes and signs the request. Orthopaedic surgeons with a collaborative prescribing agreement don’t need to submit one.
How to fill in the request
Sections 1 and 2, prescriber and patient information
Enter your name, mailing address, phone, fax and college ID. Use only the college ID, not your MSP number. Add the patient’s names, date of birth, date of application and PHN. Your fax number and the PHN are the two fields the form flags as critical.
Section 3, medication detail
Check one medication: dalteparin, biosimilar enoxaparin (the form lists the brands), nadroparin or tinzaparin. Give the duration requested in days and the dose and regimen.
A, treatment of venous thromboembolism
Choose between continuation after acute DVT or PE treated in hospital, which bridges until the INR is therapeutic on an oral anticoagulant (up to 10 days), and failure of oral anticoagulant therapy with recurrent DVT or PE despite a therapeutic INR (up to three months, then reassessed).
B, prophylaxis of venous thromboembolism
Approval lengths differ by indication: elective total knee replacement up to 14 days, elective total hip replacement up to 35 days, orthopaedic surgery for major trauma up to 10 days, lupus anticoagulant, antiphospholipid syndrome or thrombophilia up to three months, and pregnancy up to four weeks post-partum with the expected due date. After abdominal or pelvic surgery for a malignant tumour, dalteparin or biosimilar enoxaparin is covered up to 10 days, or 28 days for high-risk patients with previous VTE, anesthesia over two hours, or bed rest of four days or more after surgery.
Common reasons it’s sent back
- Cancer-associated VTE submitted on this form instead of HLTH 5469.
- More than one drug or indication checked.
- A duration longer than the indication allows.
- No expected due date for the pregnancy indication.
- Nadroparin or tinzaparin requested for post-cancer-surgery prophylaxis, which covers dalteparin and biosimilar enoxaparin only.
- A missing fax number, college ID or signature.
Submitting and who pays
Submit through Special Authority eForms or fax the form to PharmaCare at 1-800-609-4884. PharmaCare usually processes urgent requests within one business day, while routine faxed requests currently take about five weeks, which matters for a 10-day bridging course. Coverage starts on the date the approval is entered on PharmaNet and isn’t retroactive. The patient’s PharmaCare plan rules, including any deductible, still apply.