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MANDGENERIC OTIP 09/20
Request for Approval of
Brand Name Drug
OTIP Health Cla
PO Box 280
Waterloo ON N2J 4A7
1.866.783.6847 | www.otip.com
INSTRUCTIONS: (Please print all answers.)
1. Please complete sections 1, 2 and 4. Section 3 is to be completed by your physician.
2. Any charges for the completion of this form are your responsibility.
3. Please mail your completed form to the mailing address above.
SECTION 1: PLAN MEMBER BASIC PERSONAL INFORMATION
Plan Member Name (First, Middle Initial and Last) Gender
Province Postal Code
City/TownAddress (Number, Street and Apt.)
Home Telephone Number
OTIP Identiﬁcation Number
Work Telephone Number Date of Birth (mm/dd/yyyy)
The prescribed drug you are applying for as an exception is covered up to the price of the lowest cost interchangeable drug. If this exception is approved, you
will receive reimbursement up to the reasonable and customary price for the product dispensed.
The cost of the prescribed drug will only be considered under this plan, provided your physician prescribed a brand name drug instead of the lowest cost
interchangeable drug because of an adverse reaction or therapeutic failure for the patient.
SECTION 2: PATIENT INFORMATION (To be completed if different than Plan Member)
SECTION 3: PHYSICIAN’S STATEMENT (To be completed by your physician)
Patient’s Name (First, Middle Initial and Last)
DIN (Drug Identiﬁcation Number)
Relationship to Plan Member (Insured)
Date of Birth (mm/dd/yyyy)
Physician Name (First, Middle Initial and Last)
Address (Number, Street and Apt.)
Ofﬁce Telephone Number
Province Postal Code
Drug prescribed (chemical name, dosage form, strength)
What is the medical reason for the request?
Adverse reaction Therapeutic failure
Signature of Plan Member Date (mm/dd/yyyy)
Any Information provided to or collected by the Insurer in accordance with this authorization, will be kept in a beneﬁts health ﬁle.
Access to your Information will be limited to:
The Insurer and their reinsurers and service providers in the performance of their jobs;
Persons to whom you have granted access; and
Persons authorized by law.
You have the right to request access to the personal information in your ﬁle, and, where appropriate, to have any inaccurate information corrected.
SECTION 4: CERTIFICATION AND AUTHORIZATION
I certify that I, my spouse and/or my dependants of minor or major age (“Dependants”), have received all goods or services claimed and that the information
provided for this claim is true and complete. I authorize OTIP and the group beneﬁts insurance carrier (“Insurer”) that provides my beneﬁts coverage to collect,
use, maintain and disclose personal information relevant to this claim (“Information”) for the purposes of beneﬁts plan administration, audit and the assessment,
investigation and management of this claim (“Purposes”). I am authorized by my Dependants to disclose and receive their Information, for the Purposes. I
authorize any person or organization with Information, including any medical and health professionals, facilities or providers, professional regulatory bodies, any
employer, plan administrator, plan sponsor, insurer, investigative agency, and any administrators of other beneﬁts programs to collect, use, maintain and exchange
this Information with each other and with OTIP, the Insurer and their reinsurers and/or service providers, for the Purposes. I authorize the use of my OTIP ID
number for the purposes of identiﬁcation and administration. I agree a photocopy or electronic version of this authorization is valid. I acknowledge that more
QUESTIONS? CONTACT OTIP BENEFITS SERVICES AT 1-866-783-6847