What the HLTH 5483 is for
Rifaximin is a limited coverage drug in BC. This form asks PharmaCare to cover rifaximin 550 mg twice daily, taken with lactulose, to reduce the risk of overt hepatic encephalopathy coming back. PharmaCare decides on two facts: a hospitalization for encephalopathy associated with cirrhosis, and inadequate control despite the maximum tolerated dose of lactulose.
Coverage starts when the approval is entered in PharmaNet. It isn’t retroactive, so the patient pays for any fill before then.
Who completes it
A gastroenterologist or internal medicine specialist completes and signs the whole form. PharmaCare’s criteria list no practitioner exemptions, so the specialist submits a request even when they also manage the patient’s liver care long term. The patient has no part to fill in.
How to fill in the form
Section 1, Specialist information, and Section 2, Patient information
Enter the specialist’s name, mailing address, College ID and fax number. The fax number is marked critical for a timely response, and the PHN critical for processing. If PharmaCare has no fax or mailing address, it can’t send the decision back.
Section 3A, Initial coverage criteria (6 months)
Tick the confirmation that the prescriber is a gastroenterologist or internal medicine specialist, then the two clinical criteria: a hospitalization with hepatic encephalopathy associated with cirrhosis, and inadequate control on the maximum tolerated dose of lactulose. The discharge summary is the usual evidence for the first. For the second, the chart should show the lactulose dose reached and why it couldn’t go higher.
Section 3B, Exceptional renewal of coverage (1 year)
At renewal, describe the benefit and tolerability in concrete terms. The form asks you to compare the frequency of hospital admissions with the period before treatment, and to give the current lactulose regimen. A renewal that says only “doing well” gives PharmaCare nothing to compare.
Signature
Sign the consent statement confirming you’ve discussed with the patient why their information goes to PharmaCare. The signature is mandatory.
Common reasons it’s sent back
- Submitted by a prescriber who isn’t a gastroenterologist or internist.
- No hospitalization for hepatic encephalopathy, or one not linked to cirrhosis.
- Lactulose not at maximum tolerated dose, or the dose not stated.
- A renewal without admission frequency or the current lactulose regimen.
- Missing fax number, mailing address or PHN.
Submitting and who pays
Submit through PharmaCare’s SA eForms, or fax the PDF to 1-800-609-4884 or mail it to PharmaCare, Box 9652 Stn Prov Govt, Victoria, BC V8W 9P4. PharmaCare’s Special Authority page currently gives about five weeks for regular requests and one business day for urgent ones, and says eForms are usually quicker.
PharmaCare doesn’t pay for the form. Approved coverage is subject to the patient’s plan rules, including any Fair PharmaCare deductible.