Fillable Drug Prior Authorization Form (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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Drug Prior Authorization Form (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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M6453(GEN-C)-3/20
© The Canada Life Assurance Company, all rights reserved. Canada Life and design are trademarks of The Canada Life Assurance Company.
Any modification of this document without the express written consent of Canada Life is strictly prohibited.
Drug Prior Authorization Form
The purpose of this form is to obtain information required to assess your drug claim.
IMPORTANT: Please answer all questions. Your claim assessment will be delayed if this form is incomplete or contains errors.
Any costs incurred for the completion of this form are the responsibility of the plan member/patient.
Canada Life recognizes and respects the importance of privacy. Personal information collected is used for the purposes of
assessing eligibility for this drug and for administering the group benets plan. For a copy of our Privacy Guidelines, or if you have
questions about Canada Life’s personal information policies and practices (including with respect to service providers), refer to
www.canadalife.com or write to Canada Life’s Chief Compliance Ofcer.
I authorize Canada Life, any healthcare provider, my plan administrator, any insurance or reinsurance company, administrators of
government benets or patient assistance programs or other benets programs, other organizations, or service providers working with
Canada Life or any of the above, located inside or outside Canada, to exchange personal information when relevant and necessary for
these purposes. I understand that personal information may be subject to disclosure to those authorized under applicable law within
or outside Canada.
I acknowledge that the personal information is needed to assess eligibility for this drug and to administer the group benets plan.
I acknowledge that providing consent will help Canada Life to assess my claim and that refusing to consent may result in delay or
denial of my claim. Canada Life reserves the right to audit the information provided on this form at any time and this consent extends
to any audit of my claim. This consent may be revoked by me at any time by sending written instruction to that effect.
I also consent to the use of my personal information for Canada Life and its afliates’ internal data management and analytics purposes.
If the patient is a person other than myself, I conrm that the patient has given their consent to provide their personal information and
for Canada Life to use and disclose it as set out above.
I certify that the information given below is true, correct, and complete to the best of my knowledge. Failure to provide true, correct
and complete information on this form could result in revocation of any approval decision, a requirement to repay paid claims or other
appropriate action.
Form Completion Instructions:
1. Complete “Patient Information” sections.
2. Have the prescribing physician complete the “Physician Information” sections.
3. Send all pages of the completed form to us by mail, fax or email as noted below.
Note: As email is not a secur e medium, any person with concerns about their prior authorization form/medical information being
intercepted by an unauthorized party is encouraged to submit their form by other means.
Mail to: The Canada Life Assurance Company
Drug Claims Management
PO Box 6000
Winnipeg MB R3C 3A5
Fax to: The Canada Life Assurance Company
Fax 1-204-946-7664
Attention: Drug Claims Management
Email to: cldrug.services@canadalife.com
Attention: Drug Claims Management
For additional information regarding Prior Authorization and Health Case Management, please visit our Canada Life website at
www.canadalife.com or contact Group Customer Contact Services at 1-800-957-9777. Deaf or hard of hearing and require access to
a telecommunications relay service? Please contact us at 711 for TTY to Voice or 1-800-855-0511 for Voice to TTY.
Page 1 of 5
(Continued on next page)
Plan Member’s signature: Date:
Plan Member:
Plan Name:
Patient Date of Birth (DD/MM/YYYY):
If yes, please provide email address:
Please indicate preferred contact number and if there are any times when telephone contact with you about your claim would be most convenient.
Plan Number:
Address (number, street, city, province, postal code):
Plan Member ID Number:
Patient Name:
– (please print)
If Yes, a) indicate start date (DD/MM/YYYY):
b) coverage provided by:
Name of plan member:
Relationship to patient:
If Yes, name of program or other source:
1. Patient assistance program patient ID Number:
Contact Name: Phone Number:
M6453(GEN-C)-3/20
(Continued on next page)
Page 2 of 5
(if coverage is not provided by Canada Life please provide pharmacy print-out showing pur
chase of this drug)
If other plan is with Canada Life, tell us the plan and ID number:
Provide details and attach documentation of acceptance or declination:
Provide details and attach documentation of acceptance or declination:
If Yes, name of other Insurance Company:
Patient Information
Plan Member Information Complete all sections of this page
May we contact you by email? (Note that some correspondence may still need to be sent by regular mail).
Yes No
Tell us if you have been on this drug before
Is the patient currently on, or previously been on this drug? Yes No
Tell us if you have coverage with any other benefits plan
Does the patient have drug coverage under any other group benets plan?
Yes No
Tell us about any Provincial or other coverage you may have
Does the patient have coverage under a provincial program or from any other source? Yes No
Is the patient currently receiving disability benets for the condition for which this drug has been prescribed? Yes No
Tell us about any Patient Assistance Program you might be enrolled in
Has the patient enrolled in the patient assistance program for this drug? Yes No
If Yes, please provide the following information:
2. Patient assistance program contact person name and phone number:
Name of prescribing physician:
Specialty:
Address (number, street, city, province, postal code):
Telephone Number (including area code): Fax Number (including area code):
(please print)
1. Name of drug prescribed:
2. Prescribed dose and regimen:
Patient’s weight: kg (for weight-based dosing)
Date determined (MM/YYYY):
3. Medical condition: Date of diagnosis (MM/YYYY):
4. What is the anticipated duration of treatment with this drug?
Clinical details:
Clinical details:
Clinical details:
(Continued on next page)
Page 3 of 5
Physician Information
Note to Physician: In order to assess a patient’s claim for this drug, we require detailed information on the patient’s
prescription drug history as requested below.
Attach extra information if necessary. GENETIC TEST RESULTS ARE NOT REQUIRED
Physician’s Information
Is this drug being prescribed in accordance with approved Health Canada indications?
Initial request:
Yes, complete questions 1 - 7 and Initial Request section
No, prescribed use not approved by Health Canada. Complete questions 1 – 7, Initial Request section and off-label use section
Renewal request:
Complete questions 1 - 7 and Renewal Request section
5. Where will treatment be administered? Home Physician’s Ofce Private clinic Hospital in-patient Hospital out-patient
6. Drug and Treatment History – must be completed for every request.
Drug(s) and Treatment(s)
past and present
Dosing Regimen Start Date
(DD/MM/YYYY)
End Date
(DD/MM/YYYY)
Clinical Results/Outcome
Failure Intolerance Other
Failure Intolerance Other
Failure Intolerance Other
7. Is the requested drug being used in the context of a clinical trial? Yes No
M6453(GEN-C)-3/20
–
–
Start date of treatment (MM/YYYY):
Describe the patient’s response to treatment, particularly in relation to the signs and symptoms of their diseases at initial presentation.
Indicate the stage of disease and/or applicable disease severity scores.
Date determined (MM/YYYY):
Indicate the current stage of disease and/or applicable disease severity scores and the date the score was assessed. Attach copies of relevant
test results, specialist consultations or clinical notes demonstrating the severity of the patient’s disease.
Date determined (MM/YYYY):
Provide medical rationale why this drug has been prescribed instead of alternative treatments (particularly other rst line options).
How will the patient’s response to treatment be monitored or measured? (e.g. improvement in disease severity scores)
–
Initial Request Genetic test results are not required
Diagnosis
Has this medical condition been conrmed by diagnostic testing? Yes No
Diagnosis established at newborn screening? Yes No
Attach copies of relevant test results, specialist consulations or clinical notes supporting the patient’s diagnosis.
Specialties and specialty clinics involved with the patient’s
treatment plan
Most recent date the patient
was assessed
(DD/MM/YYYY)
Next date the patient will be
assessed
(DD/MM/YYYY)
Severity
Treatment Rationale
Treatment Goals
Renewal Request Genetic test results are not required
Response
Is the patient receiving clinical benet from this drug? Yes No
Attach copies of relevant test results, specialist consultations or clinical notes demonstrating a response to treatment.
Off-label use Genetic test results are not required
Is there clinical evidence supporting the off-label use of this drug? Yes No
Provide clinical literature/studies to support the request for off-label use, such as:
• At least two Phase II or two Phase III clinical trials showing consistent results of efcacy; and
• Published recommendations in evidence-based guidelines supporting its use.
Page 4 of 5
Physician Information
M6453(GEN-C)-3/20
Physician’s Signature: Date:
License Number:
Page 5 of 5
Physician Information
M6453(GEN-C)-3/20
Note for Physician: To be eligible for reimbursement, Canada Life may require your patient to purchase a drug requiring prior
authorization from a pharmacy designated by Canada Life. If applicable, a health case manager will contact you with further
information.
I certify that the information provided is true, correct, and complete.
It is important to provide the requested information in detail to help avoid delay in assessing claims for the above drug. This form may
be subject to audit. The completed form can be returned to Canada Life by mail, fax, or email.
Note: As email is not a secure medium, any person with concerns about their prior authorization form/medical information being
intercepted by an unauthorized party is encouraged to submit their form by other means.
Mail to: The Canada Life Assurance Company
Drug Claims Management
PO Box 6000
Winnipeg MB R3C 3A5
Fax to: The Canada Life Assurance Company
Fax 1-204-946-7664
Attention: Drug Claims Management
Email to: cldrug.services@canadalife.com
Attention: Drug Claims Management
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Drug Prior Authorization Form (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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Completed 24 December 2020

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