Plan Member’s signature: Date:
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This document contains both information and form fields. To read information, use the Down Arrow from a form field.
© The Great-West Life Assurance Company, all rights reserved. Any modification of this
document without the express written consent of Great-West Life is strictly prohibited.
Drug Prior Authorization Form
Cystadrops (cysteamine hydrochloride)
The purpose of this form is to obtain information required to assess your drug claim. For additional information regarding Prior
Authorization and Health Case Management, please visit our Great-West Life website at www.greatwestlife.com.
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.
Great-West 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 benets plan. For a copy of our Privacy Guidelines, or if you have
questions about Great-West Life’s personal information policies and practices (including with respect to service providers), refer to
www.greatwestlife.com or write to Great-West Life’s Chief Compliance Ofcer.
I authorize Great-West Life, any healthcare provider, my plan administrator, any insurance or reinsurance company, administrators of
government benets or patient assistance programs or other benets programs, other organizations, or service providers working with
Great-West 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 benets plan. I
acknowledge that providing consent will help Great-West Life to assess my claim and that refusing to consent may result in delay
or denial of my claim. Great-West 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.
If the patient is a person other than myself, I conrm that the patient has given their consent to provide their personal information and
for Great-West 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
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 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 Great-West Life Assurance Company
PO Box 6000
Winnipeg MB R3C 3A5
Fax to: The Great-West Life Assurance Company
Attention: Drug Services
Email to: email@example.com
Attention: Drug Services