SPECIAL AUTHORITY REQUEST FOR RHEUMATOID ARTHRITIS
ADALIMUMAB / ETANERCEPT / INFLIXIMAB
ABATACEPT / RITUXIMAB
PHARMACARE INITIAL COVERAGE OR FOR SWITCHING
Fax requests in Victoria to 250-952-1065 or, from elsewhere in BC, to 1-800-609-4884 (toll free).
OR mail requests to: PharmaCare, Box 9652 Stn Prov Govt, Victoria, BC V8W 9P4
This facsimile is Doctor-Patient privileged and contains confidential information intended only for PharmaCare. Any other distribution, copying or disclosure is strictly prohibited.
If you have received this fax in error, please write “MIS-DIRECTED” across the front of the form and fax toll free to 1-800-609-4884, then destroy the pages received in error.
Should approval be granted for this Special Authority request, PharmaCare’s authorization is solely for the purpose of providing prescription benefit for the cost of the requested
medication. PharmaCare makes no representation about the suitability of the requested medication for the patient’s medical condition or any other problem.
Forms with information missing will be returned for completion.
nAME & MAIlIng ADDRESS
CollEgE ID #
PRESCRIbIng RhEuMATologIST’S TElEPhonE #
PRESCRIbIng RhEuMATologIST’S fAx #
Please complete additional criteria information on page 2 >>
hlTh 5345 REV. 2008/06/25 PAgE 1 of 2
Page 1 of 2
ALL bIOLOgICS ARE MORE EFFICACIOUS wHEn COMbInED wITH A DMARD, SUCH AS METHOTRExATE.
yEAR of DIAgnoSIS
PATIEnT’S boDy wEIghT (kg)
CONCURRENT DMARD THERAPy:
DuRATIon of MoRnIng STIffnESS
no. of SwollEn joInTS no. of TEnDER joInTS
PRE-TREATMENT CLINICAL ASSESSMENT (Not required if last baseline assessment was submitted < 3 months ago)
DoSE of PREDnISonE
hEAlTh ASSESSMEnT quESTIonnAIRE (hAq) CoMPlETED by PATIEnT AnD ATTAChED
SECTION 3 – CLINICAL AND STATISTICAL INFORM