0670.002 01/20 CUPE 1816 1 of 2
PART 4 — DRUG REQUEST INFORMATION
Drug name Strength Dosage Duration of therapy
Diagnosis or indication Year of diagnosis
I certify the medical information provided on this form is accurate and current.
Physician’s signature
X
Date (mm-dd-yyyy)
PART 3 — PHYSICIAN INFORMATION
Physician’s name College ID
Street address City Province Postal code
Phone number (10 digits) Fax number (10 digits) Physician’s area of specialty
PART 2 — MEMBER CONSENT AND DECLARATION
IMPORTANT: This section must be signed before submitting your form
I certify that the information contained in this and other documents supporting this claim is complete and true to the best of my knowledge. I certify
that all expenses claimed under my EHC plan are medically necessary. I understand that the personal information provided on this claim, as well as
any other personal information currently held by PacificBlueCross about me and my eligible dependents will be used to determine eligibility for this
benefit, assess and pay claims. I hereby acknowledge and agree that the personal information may be exchanged between PacificBlueCross and a
health care professional, practitioner, institution or health benefits provider, government and regulatory authorities or insurer when needed for a
purpose stated above. I understand that the personal information will be kept confidential and secure. I understand that I may revoke this consent at
any time and acknowledge that should I do so, this claim may not be considered. I understand why the personal information is needed and I am aware
of the benefits and risks of consenting or refusing to consent to disclosure. I have read and understand this Member Consent and Declaration.
I authorize my physician to release my personal information to Pacific Blue Cross to obtain Blue RX approval for prescription benefit.
Member’s signature
X
Date (mm-dd-yyyy)
PART 1 — MEMBER INFORMATION
First name Last name Patient’s first name (if different than member’s name) Patient’s last name
Patient’s birthdate (mm-dd-yyyy) Patient’s weight Patient’s height Daytime phone number (10 digits) Policy number ID number
Street address City Province Postal code
DRUG ELIGIBILITY
INQUIRY FORM
Mail: PO Box 7000, Vancouver, BC V6B 4E1
|
Drop it off: 4250 Canada Way, Burnaby, BC
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Fax: 604 419-2689
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Toll-free fax: 1 844 419-2689
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pac.bluecross.ca
HOW TO COMPLETE THIS FORM:
MEMBERS — Please complete BLACK portions of this form.
PHYSICIANS — Please complete RED portion of this form.
Incomplete or forms completed by Patient Support Programs will
not be accepted. Don’t forget to sign Part 2 — Member Consent and
Declaration before you submit your claim.
The patient is responsible for any fees charged by the physician for
completion of this form. These fees are not eligible for reimbursement
under your Pacific Blue Cross Extended Health Care plan.
Completion of this form does NOT imply approval for this drug.
Coverage is based on the provisions of your Extended Health Care plan.
Not eligible under the BC PharmaCare Authority Program:
Does not meet PharmaCare Special Authority criteria (include detailed explanation of the why criteria not met in Part 6 — Additional information)
Indication is not eligible under BC PharmaCare Special Authority Program
Drug is not listed by BC PharmaCare (include detailed explanation as to why BC PharmaCares benefit drug(s) cannot be tried in
Part 6 — Additional information)
Other (Please use Part 6 — Additional information if more space is required):
Cancer Therapy — Ensure BCCA protocol codes for prior and current therapy are included in Part 5 of this form.
Attach a copy of the primary article that supports your request
Not eligible for coverage by BC Cancer Agency:
Does not meet BCCA criteria for coverage (attach copy of the BCCA denial)
Indication is not listed under BCCA benefit drug list (attach copy of the BCCA denial)
Drug is not listed on the BCCA benefit drug list
Other (Please use Part 6 — Additional information if more space is required):
Where will the drug be administered?:
DO NOT WRITE IN THIS SPACE
