What the HLTH 5818 is for
The form asks PharmaCare to cover one course of IV iron for iron deficiency anemia. It lists three products: iron sucrose 20 mg/mL for adults, iron isomaltoside 100 mg/mL for adults, and ferric carboxymaltose 50 mg/mL from age 1. PharmaCare decides on a lab-confirmed diagnosis, a reason oral iron won’t work, and an infusion setting that can manage hypersensitivity reactions.
Approval covers one course, not ongoing treatment. Coverage starts when the approval is entered in PharmaNet and isn’t retroactive.
Who completes it
The prescriber completes and signs it. PharmaCare lists no practitioner exemptions. The patient has no part to fill in.
How to fill in the form
Section 1, Prescriber information, and Section 2, Patient information
Enter your name, mailing address, College ID and fax number, and the patient’s PHN. PharmaCare can’t reply without a fax number or mailing address.
Section 3, Medication requested
Pick one product. The initial course limits differ: up to 1,000 mg cumulative for iron sucrose and up to 2,000 mg for iron isomaltoside or ferric carboxymaltose. Each initial course must be filled within 28 days. A renewal is one more course, at least four weeks after the initial dose was dispensed. Book the infusion so the fill falls inside the 28 days.
Section 4, Criteria for coverage
Tick the documented diagnosis of iron deficiency anemia confirmed by labs, such as hemoglobin, ferritin and transferrin saturation. Tick the confirmation that the infusion will happen where hypersensitivity reactions can be monitored and managed.
Then tick at least one of three reasons. A failed oral trial needs the product and duration, at least four weeks at a treatment dose. Intolerance needs at least two oral products with details of what happened. A contraindication needs a rationale: clinical malabsorption such as short bowel syndrome or inflammatory bowel disease, severe or chronic blood loss oral iron can’t keep up with, or another reason you specify.
Signature
Sign the consent statement confirming you’ve told the patient why their information goes to PharmaCare. The signature is mandatory.
Common reasons it’s sent back
- No lab values supporting iron deficiency anemia.
- An oral iron trial shorter than four weeks, or a prophylactic dose.
- Intolerance claimed for only one oral product.
- The monitored setting box left unticked.
- An adult-only product requested for a patient under 18.
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.
PharmaCare doesn’t pay for the form. The drug is covered under the patient’s plan rules, including any Fair PharmaCare deductible.