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Plan Member’s signature:
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
© 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
Soliris (eculizumab)
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 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 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:
Attention: Drug Claims Management
For additional information regarding Prior Authorization and Health Case Management, please visit our Canada Life website at 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.
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Soliris (eculizumab)
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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:
If Yes, a) indicate start date (DD/MM/YYYY):
b) coverage provided by:
(if coverage is not provided by Canada Life please provide pharmacy print-out showing purchase of this drug)
If Yes, name of other Insurance Company:
If other plan is with Canada 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:
(please print)
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:
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Soliris (eculizumab)
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Name of prescribing physician:
Address (number, street, city, province, postal code):
Telephone Number (including area code): Fax Number (including area code):
mg every 2 weeks
Provide rationale:
(include date of initial diagnosis) (MM/YYYY):
3. What is the anticipated duration of treatment with this drug?
5. Please provide medical rationale why this drug has been prescribed instead of an alternate drug in the same therapeutic class:
Clinical details:
Clinical details:
Clinical details:
(please print)
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 dosage and frequency. Include initial loading dose if applicable:
Other (please specify):
mg every week for weeks, 1 week later, 5
2. Health Canada Indication
atypical Hemolytic Uremic Syndrome (aHUS)
Myasthenia Gravis (gMG)
Neuromyelitis Optica Spectrum Disorder (NMOSD)
Paroxysmal nocturnal hemoglobinuria (PNH)
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 - 6 and Off-label use
4. 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
End Date
Clinical Results/Outcome
Failure Intolerance Other
Failure Intolerance Other
Failure Intolerance Other
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Physician’s Information (continued) (please print)
Physician Information
Soliris (eculizumab)
If yes, please provide a description and include any supporting test results or clinic notes to con rm.
Has patient experienced stabilization of their disease? Please provide a desciption of which TMA complications have stabilized since
starting eculizumab. Please provide clinic notes to describe patient’s benefit from eculizumab therapy
Atypical Hemolytic Uremic Syndrome (aHUS)
Initial Requests/Recommencement Requests:
Initial request
Recommencement request (patient has previously been diagnosed with aHUS and responded to treatment with Soliris)
Shiga toxin-related HUS has been ruled out Yes No Submit report.
Secondary causes of thrombotic microangiopathy, such as pregnancy, HIV, collagen vascular disease, drugs, malignancy, stem cell transplant, or
malignant hypertension have been ruled out Yes No
Does patient have any extra-renal TMA-related manifestations? Yes No
For renewals, provide details pertaining to last 12 months.
Does patient have pre-existing kidney dysfunction? Yes No
If yes, please include a copy of laboratory results showing baseline levels prior to aHUS presentation in addition to current results
Required laboratory reports for initial requests
Baseline ADAMTS-13 report required with submission. Please check one of the following:
Submitted with initial request
Not available for initial request, will be submitted once available
If ADAMTS-13 sample not collected prior to plasma exchange or infusion, it may be taken 1-2 weeks following the last plasma exchange
and must be submitted with the renewal request.
Peripheral blood smear
Direct antiglobulin test
For all requests (initial, recommencement, renewal):
Laboratory reports required for the last 12 months with initial requests and since previous request for renewals
Indicate if attached by checking box below
Serum Creatinine
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Physician Information
Soliris (eculizumab)
Please indicate the Myasthenia Gravis- specific Activities of Daily Living scale (MG-ADL) within the last 3 months (copy must be
submitted): Date:
Please indicate the Myasthenia Gravis- specific Activities of Daily Living scale (MG-ADL) within the last 3 months (copy must be
submitted): Date:
Physician’s Information (continued) (please print)
Myasthenia Gravis (gMG)
Soliris will be taking in combination with:
Anticholinesterase agents
Immunosuppressive agents
Is the patient positive for anti-acetylcholine receptor (AchR) antibodies? Yes No
Laboratory test results must be submitted.
Please indicate the Myasthenia Gravis Foundation of America (MGFA) clinical classification:
Class I Class II Class III Class IV Class V
Neuromyelitis Optica Spectrum Disorder (NMOSD)
Is patient anti-aquaporin-4 (AQP4) antibody positive? Yes No
Antibody test result must be submitted.
Please check which of the following core clinical characteristics of NMOSD the patient has experienced.
Please submit clinic notes to confirm clinical features experienced below.
Clinical Feature Date(s) Of Occurrence (MM/YYYY)
Optic neuritis
Acute myelitis
Area postrema syndrome
Acute brainstem syndrome
Symptomatic narcolepsy or acute diencephalic clinical
syndrome with NMOSD-typical diencephalic MRI lesions
Symptomatic cerebral syndrome with NMOSD-typical brain lesions
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Physician Information
Soliris (eculizumab)
Yes No
Physician’s Information (continued) (please print)
Describe the patient’s response to treatment, particularly in relation to the signs and symptoms of their disease at initial presentation.
Has patient experienced at least 2 relapses in the past 12 months, or 3 relapses in the past 24 months (at least 1 of which had occurred
within the past 12 months)? Yes No
Have other diagnoses (such as multiple sclerosis) have been ruled out? Yes No
Is the patient receiving clinical benefit from this drug? Yes No
Has the patient experienced a reduction in the number and/or severity of relapses or signs and symptoms of NMOSD since starting Soliris
therapy? Yes No
Please submit clinic notes supporting the patient’s response to Soliris therapy.
Paroxysmal nocturnal hemoglobinuria
Required laboratory reports (submit documentation with initial request):
Provide all reports for the last 12 months on initial request and indicate if attached below.
Yes No
Serum creatinine
Serum LDH
Hemoglobin and/or Haptoglobin
Upon renewal, provide lab data and treatments since previous request.
Note: an assessment cannot be made unless all of the tests above have been performed and reports submitted.
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Physician Information
Soliris (eculizumab)
Physician’s Information (continued) (please print)
Please provide any relevant information related to the disease and attach supporting documentation.
Further clinical documentation - check all that apply and provide details.
Does the patient have any of the following: Yes No Comments/dates (DD/MM/YYYY)
A history of a major adverse vascular
event (MAVE)?
If yes, did the patient require
Pulmonary insufficiency
Renal insufficiency
Smooth muscle spasm
Aplastic anemia
Myelodysplastic syndrome
Other myelopathies
Transfusion History: provide details for the last 12 months on initial requests. Upon renewal, provide details since previous request.
Transfusion date
Other condition (Health Canada approved)
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Date of initial diagnosis (DD/MM/YYYY):
Provide medical rational why Soliris 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 efficacy since previous request.
Physician Information
Soliris (eculizumab)
Physician’s Signature: Date:
License Number:
Off-label use
Questions 1 - 6 must be completed.
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 efficacy; and
Published recommendations in evidence-based guidelines supporting its use.
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
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:
Attention: Drug Claims Management