What the HLTH 5465 is for
HLTH 5465 requests PharmaCare coverage of a cholinesterase inhibitor for mild to moderate Alzheimer’s disease, with or without Parkinsonian features (Lewy bodies), a vascular component, or mixed dementia. Donepezil must be tried first. Galantamine and rivastigmine are covered only as a switch for intolerance. The current edition, dated 2026/08/12, notes that only SMMSE and GDS scores count.
Who completes it
The prescriber completes and signs the request. No specialty is exempt. Complete Sections 1 to 3 for an initial request or a switch, and Sections 1, 2 and 4 for a renewal.
How to fill in the request
Sections 1 and 2, prescriber and patient information
Enter your name and clinic address, phone, fax and college ID only, and the patient’s names, date of birth, date of application and PHN.
Section 3, initial coverage, donepezil
Check donepezil 5 to 10 mg daily, confirm the diagnosis, and give the GDS stage and the SMMSE score. If the patient can’t do the SMMSE because of functional illiteracy, tick that box instead. A MoCA result in the chart doesn’t substitute, so do the SMMSE at the visit if none is recorded.
Section 3, switching to galantamine or rivastigmine
Check galantamine 16 to 24 mg or rivastigmine oral tablets 6 to 12 mg daily, then describe the intolerance in detail, including the intolerance to donepezil. Repeat the diagnosis, GDS and SMMSE. Use Section 5 on page 2 if you need more room.
Section 4, renewal
Select the drug the patient is on and confirm the diagnosis, a current GDS stage and SMMSE score, or functional illiteracy. The first renewal gives one year and the second gives indefinite coverage.
Common reasons it’s sent back
- A MoCA score given instead of an SMMSE.
- No GDS stage recorded.
- Galantamine or rivastigmine requested without a donepezil trial.
- A switch for lack of effect rather than intolerance.
- Intolerance named without its nature or severity.
- A renewal sent on page 1 only, without Section 4 on page 2.
Submitting and who pays
Submit through Special Authority eForms, where donepezil is eligible for automatic approval, or fax the form to 1-800-609-4884. Coverage starts on the date the approval is entered on PharmaNet. The criteria apply to all PharmaCare plans, including Plan G, and the patient pays according to their plan and deductible.