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This version of the form is not currently in use and is provided for reference only. Download this version of
Form HLTH5368
for the current year.
Form HLTH5368 Special Authority Request - Adalimumab / Infliximab / Vedolizumab for Moderate to Severe Active Crohn's / Fistulizing Crohn's Disease - Initial / Switch Coverage - British Columbia, Canada
Form HLTH5368 Special Authority Request - Adalimumab/Infliximab/Vedolizumab for Moderate to Severe Active Crohn's/Fistulizing Crohn's Disease - Initial/Switch Coverage in British Columbia, Canada is used to request coverage for medications (Adalimumab, Infliximab, Vedolizumab) that are used to treat patients with moderate to severe active Crohn's disease or fistulizing Crohn's disease. The form is used in British Columbia, Canada to apply for initial coverage or to switch coverage for these specific medications.
The form HLTH5368 Special Authority Request - Adalimumab/Infliximab/Vedolizumab for Moderate to Severe Active Crohn's/Fistulizing Crohn's Disease - Initial/Switch Coverage in British Columbia, Canada is filed by the prescribing healthcare professional or the patient's authorized representative.
FAQ
Q: What is the purpose of the HLTH5368 Special Authority Request?
A: The purpose of the HLTH5368 Special Authority Request is to apply for coverage for Adalimumab, Infliximab, or Vedolizumab for the treatment of Moderate to Severe Active Crohn's Disease or Fistulizing Crohn's Disease.
Q: Who is eligible to apply for the HLTH5368 Special Authority Request?
A: Patients with Moderate to Severe Active Crohn's Disease or Fistulizing Crohn's Disease in British Columbia, Canada are eligible to apply for the HLTH5368 Special Authority Request.
Q: What medications can be requested through the HLTH5368 Special Authority Request?
A: Adalimumab, Infliximab, and Vedolizumab can be requested through the HLTH5368 Special Authority Request for the treatment of Moderate to Severe Active Crohn's Disease or Fistulizing Crohn's Disease.
Q: Is this coverage for initial treatment or switching from a different medication?
A: The HLTH5368 Special Authority Request can be used for both initial treatment and switching from a different medication for Moderate to Severe Active Crohn's Disease or Fistulizing Crohn's Disease.
Q: Is the coverage specific to British Columbia?
A: Yes, the coverage provided through the HLTH5368 Special Authority Request is specific to British Columbia, Canada.
Download Form HLTH5368 Special Authority Request - Adalimumab / Infliximab / Vedolizumab for Moderate to Severe Active Crohn's / Fistulizing Crohn's Disease - Initial / Switch Coverage - British Columbia, Canada
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