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

Page 1 of 5

(Continued on next page)

Plan Member’s signature: Date:

This document contains both information and form fields. To read information, use the Down Arrow from a form field.

M6453(JAKAVI)-1/20

Any modification of this document without the express written consent of Canada Life is strictly prohibited.

Drug Prior Authorization Form

Jakavi (ruxolitinib)

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 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

For additional information regarding Prior Authorization and Health Case Management, please visit our Canada Life website

www.canadalife.com or contact Group Customer Contact Services at 1-800-957-9777.

Jakavi (ruxolitinib)

–

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.

n n If yes, please provide email address:

n n

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)

n n

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:

n n

If Yes, name of program or other source:

Provide details and attach documentation of acceptance or decline:

n n

1. Patient assistance program patient ID Number:

Contact Name: Phone Number:

(Continued on next page)

M6453(JAKAVI)-1/20

Page 2 of 5

(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:

Jakavi (ruxolitinib)

(please print)

Name of prescribing physician:

Specialty:

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

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

1. Prescribed dose and regimen:

(MM/YYYY)

n :

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

n n n n n

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

n n n

Clinical details:

n n n

Clinical details:

n n n

Clinical details:

M6453(JAKAVI)-1/20

(Continued on next page)

Page 3 of 5

(include date of initial diagnosis):

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

2. Health Canada indication

Polycythemia Vera (PV)

Primary myelobrosis, postpolycythemia vera myelobrosis or post-essential thrombocythemia myelobrosis

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

(DD/MM/YYYY)

End Date

(DD/MM/YYYY)

Clinical Results/Outcome

Failure Intolerance Other

Physician Information

Jakavi (ruxolitinib)

n n

Please provide patient’s current ECOG score:

Please provide DIPSS (Dynamic International Prognostic Scoring System) score:

n n

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

M6453(JAKAVI)-1/20

Page 4 of 5

Polycythemia Vera

Has patient received a trial of hydroxyurea? Yes No

Does patient show evidence of hydroxyurea resistance? Yes No

Select all that apply:

Need for phlebotomy to keep hematocrit <45% after 3 months of hydroxyurea

Uncontrolled myeloproliferation with a platelet count of >400 × 10

/L and white blood cell count of >10×10

/l after 3 months of

hydroxyurea

Failure to reduce massive splenomegaly by greater than 50% as measured by palpation, or failure to completely relieve splenomegaly

symptoms after 3 months of hydroxyurea

Does patient show evidence of hydroxyurea intolerance? Yes No

Select all that apply:

Absolute neutrophil count <1.0×10

/L OR platelet count <100×10

/L or hemoglobin <100g/L at the lowest effective dose of Hydroxyurea

Presence of hydroxyurea-related non-hematological toxicities (leg ulcers, gastrointestinal toxicity, fevers, mucocutaneous manifestations,

pneumonitis, or skin cancers)

Primary myeloﬁbrosis, postpolycythemia vera myeloﬁbrosis or post-essential thrombocythemia myeloﬁbrosis

Please indicate patient diagnosis:

Primary myelobrosis

Postpolycythemia vera myelobrosis

Post-essential thrombocythemia myelobrosis

Has the patient received a trial of hydroxyurea? Yes No

If yes, did hydroxyurea fail to control disease and symptoms? Yes No

Please ensure medication history chart is complete

Does the patient have symptomatic splenomegaly? Yes No

Other condition (Health Canada approved)

Physician Information

Jakavi (ruxolitinib)

Date of initial diagnosis (DD/MM/YYYY):

n n

Provide medical rationale why this drug has been prescribed off-label instead of an alternative 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 efcacy since previous request.

Physician’s Signature: Date:

License Number:

M6453(JAKAVI)-1/20

Page 5 of 5

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 efcacy; 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

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

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