What the HLTH 5391 is for
HLTH 5391 requests PharmaCare coverage of dabigatran 110 mg or 150 mg for stroke and systemic embolism prevention in non-valvular atrial fibrillation. Because apixaban and rivaroxaban are regular benefits, PharmaCare expects a specific reason for dabigatran, and the form asks for it through the warfarin criteria.
Who completes it
The prescriber completes and signs the request. No specialty is exempt.
How to fill in the request
Sections 1 and 2, prescriber and patient information
Enter your name, mailing address, phone, fax and college ID only, and the patient’s names, date of birth, date of application and PHN.
Section 3, medication and dose selection
Select dabigatran and the strength. The form’s dosing note recommends 110 mg twice daily for creatinine clearance or eGFR of 30 to 49 mL/min and 150 mg twice daily at 50 mL/min or more. PharmaCare’s criteria page also notes the product monograph recommends 110 mg twice daily from age 80.
Section 4A, diagnosis and risk factors
Confirm non-valvular AF, without hemodynamically significant rheumatic valvular disease or a prosthetic valve, and check at least one CHADS2 risk factor: heart failure, hypertension, age 75 or older, diabetes, or prior stroke or TIA. For patients 75 and older, renal function must have been adequate and stable for at least three months. Have the eGFR history in front of you before you sign.
Section 4B, why warfarin isn’t suitable
Check one reason: INR out of range on at least 35% of tests after at least two months of warfarin, inability to monitor INR regularly, or another reason explained in as much detail as you can. Sign in Section 5.
Common reasons it’s sent back
- No CHADS2 risk factor checked.
- A patient 75 or older with no documented stable renal function.
- A warfarin trial shorter than two months, or no time-in-range figure.
- An “other” reason that doesn’t explain why warfarin, or a regular benefit alternative, won’t work.
- Missing fax number, college ID or signature.
Submitting and who pays
Dabigatran is eligible for automatic approval when submitted through Special Authority eForms. You can also fax the form to 1-800-609-4884, which takes longer and isn’t auto-adjudicated. Coverage starts when the approval is entered on PharmaNet. The patient pays according to their PharmaCare plan and deductible.