Drug Exception Request Form
Use this form to request coverage of a drug that is not automatically covered under your drug plan. Provide the requested information to ensure
timely assessment of your claim.
PLAN MEMBER INFORMATION
Policy Number: Student Name:
Student ID #: Address:
PATIENT INFORMATION
Patient: Relationship: Date of Birth:
I hereby authorize The Great-West Life Assurance Company to use the information provided herein and/or consult with the below stated physician
to determine eligibility for special authorization drug benets.
Student/Patient’s signature: Date:
If you are a resident of British Columbia, Saskatchewan or Manitoba and the requested drug has been approved by the Provincial Drug Program on
an exception basis, please send us a copy of the government approval letter. (If this section applies to you, then you do not need to complete the
remainder of this form.) Coverage will be added to your Pay Direct Drug Card (myBenets Card) within 2 -3 days.
©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.
M6586A-11/12
BRITISH COLUMBIA, SASKATCHEWAN OR MANITOBA residents:
PLEASE HAVE THE FOLLOWING COMPLETED BY YOUR PHYSICIAN:
Physician’s Name: Registration Number:
Address:
Telephone Number: Fax Number:
In order to be considered for a drug exception, you must have tried at least one medication on your plan’s applicable formulary.
Diagnosis:
Drug prescribed and DIN #, if known:
Alternative treatments attempted (Please provide specic drug names and din #’s, if known. Please note this request will not be considered if this
section is not completed).
If no other medication was tried, please explain why this drug must be prescribed (for example a contraindication resulting from an allergy
reaction.
Information on requested drug
Drug Name: Dose Prescribed:
Physician’s signature: Date:
REQUIRED INFORMATION
It is important that all of the above information is provided in detail to avoid delay in assessing claims for the above drug. Please note that the plan does
not cover any fees for providing information. Once completed, this form can be returned to Great-West Life at the address, fax # or email shown below.
Mail to: The Great-West Life Assurance Company Fax to: Drug Services
PO Box 6000 The Great-West Life Assurance Company
Winnipeg MB R3C 3A5 Fax 1.204.946.7664
Canada
Attention: Drug Services Email to: gwldrug.services@gwl.ca
