Fill - Free fillable REQUEST FOR REIMBURSEMENT OF A MEDICATION NOT INCLUDED (Desjardins Insurace) PDF form

13175E02 (2020-02)

REQUEST FOR REIMBURSEMENT OF A MEDICATION NOT INCLUDED IN THE





Desjardins Insurance life health rerement logo

YYYY MM DD

Name of policyholder Group no. Cercate no.

Last name and rst name of member Sex Date of birth

Address - No., street, apt. City Province Postal code

Last name and rst name of paent Sex Date of birth

Relaonship to member DIN (Drug Idencaon Number)

All the informaon I have provided on the claim form is accurate and complete. I acknowledge having read the Personal Informaon Management secon. I authorize

Desjardins Insurance strictly for the purposes of managing my le and seling this claim to: (a) collect from any person or legal enty, or from any public or parapublic

organizaon, only the informaon deemed necessary to manage my le. The non-exhausve list of sources from which informaon may be collected includes healthcare

professionals or facilies, insurance companies; (b) communicate to the said persons or organizaons only the personal informaon about me that is deemed necessary

for the purposes of my le; (c) when necessary, use the personal informaon it may have about me in exisng les that are now closed. This authorizaon is also valid for

the collecon, use and communicaon of personal informaon concerning my dependents, insofar as applicable to the claim. A photocopy of this authorizaon is as valid

as the original.

Signature of member

Date

Signature of insured

 

Desjardins Financial Security Life Assurance Company, hereinaer Desjardins Insurance, handles the personal informaon it has on you in a condenal manner. Desjardins

Insurance keeps this informaon on le so that you may benet from group insurance services oered by the Company. This informaon is consulted solely by Desjardins

Insurance employees who need to do so in the course of their work. Desjardins Insurance may compile anonymized personal informaon for stascal and informaonal

purposes. Desjardins Insurance may also communicate with plan members to provide them with opmal health management. You have the right to consult your le. You may

also have informaon corrected if you demonstrate that it is inaccurate, incomplete, ambiguous or not useful. To do so, you must send a wrien request to the following address:

Privacy Ocer, Desjardins Insurance, 200, rue des Commandeurs, Lévis, Québec, G6V 6R2. Desjardins Insurance may use the client list to oer its clients an insurance product

following the terminaon of their group insurance. If you do not wish to receive these oers, you may have your name removed from the list. To do so, you must send a wrien

request to the Privacy Ocer at Desjardins Insurance.



• Any charges for the compleon of this form are the member’s responsibility.

• The member must complete secons A and C.

• If the request is for the reimbursement of a medicaon that is not included in the er-1 managed formulary, the aending physician must complete secons D and F.

If the request is for the reimbursement of a brand name medicaon, the aending physician must complete secons E and F. The member must have read and

understood the instrucons provided in these secons.

• This request will be assessed based on the medical informaon provided and may be reviewed by our physician or pharmacist.

IMPORTANT INFORMATION

A PATIENT'S IDENTIFICATION 

B 

C DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION

Address C. P. 3950 Lévis Québec G 6 V 8 C 6 web site desjardins life insurance dot com slash plan member Telephone 1 8 0 0 2 6 3 1 8 1 0

C. P. 3950

Lévis (Québec) G6V 8C6

desjardinslifeinsurance.com/planmember

Tel.: 1-800-263-1810

Fax: 418-838-2134 or 1-877-838-2134

NEW REQUEST





Please send form by fax: 4 1 8 8 3 8 2 1 3 4 toll free: 1 8 7 7 8 3 8 2 1 3 4 or by mail: Desjardins Insurance CP 3950 Lévis Québec G 6 V 8 C 6

• The medicaon for which you are applying for an excepon is not included in the er-1 managed formulary and is currently covered at a lower percentage. If this

excepon is approved, the medicaon will be covered at a higher percentage.

• The excepon will only be approved if the aending physician provides an acceptable medical reason that explains why the paent is unable to take a therapeuc

alternave listed in the er-1 managed formulary.

• The approved medicaon will be covered up to the lowest cost generic equivalent available on the market. If the paent cannot take the generic equivalent either,

another acceptable medical reason will need to be provided in secon E.

E BRAND NAME MEDICATION

  

• The brand name medicaon for which you are applying for an excepon is currently covered up to the lowest cost generic equivalent available on the market. If this

excepon is approved, the medicaon will be covered at the price provided for the brand name medicaon.

• The excepon will only be approved if the aending physician provides an acceptable medical reason to support why the paent is unable to take the lowest cost

generic equivalent available on the market.

1. What is the paent's diagnosis?

2. Brand name drug requested:

Name and strength: DIN:

Dosage:

3. Generic drug tried:

Name and strength: DIN:

Dosage: Treatment period: From To

4. What is the medical reason for the request: Allergies Adverse reacon Therapeuc failure Other:

The eects aributable to the adverse or allergic reacon are:

Mild (no intervenon required) Moderate (minimal intervenon required) Severe (hospitalizaon required) Life threatening

Please describe the adverse or allergic reacon observed (nature, extent, severity):

1. What is the paent's diagnosis?

2. Drug requested:

Name and strength: DIN:

Dosage:

3. Alternave drug listed in the er-1 managed formulary that the paent has tried:

Name and strength: DIN:

Dosage: Treatment period: From To

4. What is the medical reason for the request: Allergies Adverse reacon Therapeuc failure Other:

The eects aributable to the adverse or allergic reacon are:

Mild (no intervenon required) Moderate (minimal intervenon required) Severe (hospitalizaon required) Life threatening

Please describe the adverse or allergic reacon observed (nature, extent, severity):

D 

  

( ) -

Last name and rst name of physician (PLEASE PRINT)

Address - No., street, suite City Province Postal code

Telephone no.: Fax no.:

 

F  IDENTIFICATION 

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REQUEST FOR REIMBURSEMENT OF A MEDICATION NOT INCLUDED (Desjardins Insurace)

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