What the HLTH 5469 is for
HLTH 5469 requests PharmaCare coverage of LMWH for the treatment of venous thromboembolism in a patient with cancer. Dalteparin, tinzaparin and biosimilar enoxaparin are covered, with approvals of up to six months. Prophylaxis after abdominal or pelvic cancer surgery is a different indication and goes on HLTH 5338.
Who completes it
The prescriber completes and signs the request.
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, then the patient’s names, date of birth, date of application and PHN.
Section 3, medication detail
Check one medication: dalteparin, tinzaparin or biosimilar enoxaparin, for which the form lists the covered brands. Give the duration requested in months, up to six, and the dose and regimen.
A, initial coverage criteria
Confirm treatment of VTE associated with cancer and give the date of the most recent VTE. Take it from the imaging report rather than the referral letter.
B, exceptional renewal of coverage
For an extension, give the rationale for continuing anticoagulation. Name what makes the risk ongoing, such as active malignancy, ongoing chemotherapy, or recurrent thrombosis, rather than restating the diagnosis.
Common reasons it’s sent back
- Both A and B completed, or neither.
- No date for the most recent VTE.
- A duration over six months.
- A renewal with no rationale for extended treatment.
- Cancer-surgery prophylaxis submitted here instead of on HLTH 5338.
- Missing fax number, college ID or signature.
Submitting and who pays
Submit through Special Authority eForms or fax the form to 1-800-609-4884. Urgent requests are usually processed within one business day. Coverage starts on the date the approval is entered on PharmaNet, so injections dispensed earlier aren’t covered. The patient pays according to their PharmaCare plan and deductible.