Fill - Free fillable Drug Prior Authorization Form Deferasirox (Great-West Life Insurance for Personal, Group & Benefits in Canada) PDF form

Plan Member’s signature: Date:

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M6453(DEFERASI)-7/19

document without the express written consent of Great-West Life is strictly prohibited.

Drug Prior Authorization Form

Deferasirox

The purpose of this form is to obtain information required to assess your drug claim. Approval for coverage of this drug may be

reassessed at any time at Great-West Life’s discretion. 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 benets 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 Ofcer.

I authorize Great-West 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

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 benets 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 conrm 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

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 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

Drug Services

PO Box 6000

Winnipeg MB R3C 3A5

Fax to: The Great-West Life Assurance Company

Fax 1-204-946-7664

Attention: Drug Services

Email to: gwldrug.services@gwl.ca

Attention: Drug Services

Deferasirox

– (please print)

Plan Member: Patient Name:

Plan Name: Plan Number: Plan Member ID Number:

Patient Date of Birth (DD/MM/YYYY): Address (number, street, city, province, postal code):

Please indicate preferred contact number and if there are any times when telephone contact with you about your claim would be most convenient.

If yes, please provide email address:

If Yes, a) indicate start date (DD/MM/YYYY):

b) coverage provided by:

(if coverage is not provided by Great-West Life please provide pharmacy print-out showing purchase of deferasirox)

If Yes, name of other insurance company:

If other plan is with Great-West Life, tell us the plan and ID number:

Name of plan member:

Relationship to patient:

Provide details and attach documentation of acceptance or decline:

If Yes, name of program or other source:

Provide details and attach documentation of acceptance or decline:

1. Patient assistance program patient ID Number:

Contact Name: Phone Number:

(Continued on next page)

M6453(DEFERASI)-7/19

Page 2 of 6

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 deferasirox? 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 deferasirox 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 deferasirox? Yes No

If Yes, please provide the following information:

2. Patient assistance program contact person name and phone number:

Deferasirox

(please print)

Name of prescribing physician:

Specialty:

Address (number, street, city, province, postal code):

Telephone Number (including area code): Fax Number (including area code):

2. Prescribed dose and regimen:

Patient’s weight: kg (for weight-based dosing)

Date determined (MM/YYYY):

(include date of initial diagnosis) (MM/YYYY):

4. What is the anticipated duration of treatment with this drug?

6. Please provide medical rationale why this drug has been prescribed instead of an alternate drug in the same therapeutic class:

M6453(DEFERASI)-7/19

(Continued on next page) Page 3 of 6

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

1. Prescribed Medication:

Exjade

Jadenu

3. Health Canada Indication

Chronic iron overload in patients with transfusion-dependent anemias

Chronic iron overload in patients with non-transfusion-dependent thalassemia syndromes

Complete questions 1 – 6 and Physician’s information

Other (approved by Health Canada):

Other (prescribed use is not approved by Health Canada):

Complete questions 1 – 6 and Other condition (Health Canada approved)

Complete questions 1 – 4, 6 and Off-label use

5. Where will treatment be administered? Home Physician’s Ofce Private clinic Hospital in-patient Hospital out-patient

Physician Information

Deferasirox

Physician’s Information (continued) (please print)

Clinical details:

If yes, please provide rationale why combination therapy is being prescribed, and ensure all details of previous treatment and dose increase

attempts are documented in the treatment history chart above.

M6453(DEFERASI)-7/19

Page 4 of 6

Start Date (DD/MM/YYYY) End Date (DD/MM/YYYY)

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

Transfusion-dependent iron overload

Has the patient received intermittent or regular transfusions in the last 12 months? Yes No

If yes, please detail start and end dates of transfusions patient has received in the last 12 months:

Start Date (DD/MM/YYYY) End Date (DD/MM/YYYY)

Patient is:

Treatment-naïve (has not previously tried other iron chelation therapy such as deferoxamine, deferiprone or deferasirox).

Treatment-experienced (has tried ≥1 other chelation therapy(ies) such as deferoxamine, deferiprone or deferasirox).

Please detail in the medication chart above.

Please provide the following:

Laboratory report indicating patient’s current serum ferritin levels (must be dated within 3 months prior to request date)

Patient’s liver iron concentration (LIC): mg/g dry weight

Will deferasirox be used in combination with another iron chelator? Yes No

Physician Information

Deferasirox

Please provide any relevant information related to the disease and attach supporting documentation.

Provide medical rationale why this drug has been prescribed off-label instead of an alternate drug with an approved indication for this condition.

Provide any pertinent medical history or information to support this off-label request.

If this is a renewal request, provide documentation showing treatment efcacy since previous request.

M6453(DEFERASI)-7/19

Page 5 of 6

Start Date (DD/MM/YYYY) End Date (DD/MM/YYYY)

Non-transfusion-dependent thalassemia syndromes

Has the patient received intermittent or regular transfusions in the last 6 months? Yes No

If yes, please detail start and end dates of transfusions patient has received in the last 6 months:

Start Date (DD/MM/YYYY) End Date (DD/MM/YYYY)

Patient is:

Treatment-naïve (has not previously tried other iron chelation therapy such as deferoxamine, deferiprone or deferasirox).

Treatment-experienced (has tried ≥1 other chelation therapy(ies) such as deferoxamine, deferiprone or deferasirox).

Please detail in the medication chart above.

Please provide the following:

Laboratory report indicating patient’s current serum ferritin levels (must be dated within 3 months prior to request date)

Patient’s liver iron concentration (LIC): mg/g dry weight

Other condition (Health Canada approved)

Off-label use

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.

Physician Information

Deferasirox

Physician’s Signature: Date:

License Number:

M6453(DEFERASI)-7/19

Page 6 of 6

Note for Physician: To be eligible for reimbursement, Great-West Life may require your patient to purchase a drug requiring

prior authorization from a pharmacy designated by Great-West 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 Great-West 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 Great-West Life Assurance Company

Drug Services

PO Box 6000

Winnipeg MB R3C 3A5

Fax to: The Great-West Life Assurance Company

Fax 1-204-946-7664

Attention: Drug Services

Email to: gwldrug.services@gwl.ca

Attention: Drug Services

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