Source: http://docplayer.net/16410119-Prior-authorization-pharmacy-and-health-case-management-information-prior-authorization-pharmacy-information-health-case-management.html
Timestamp: 2019-01-20 05:59:40
Document Index: 647504927

Matched Legal Cases: ['art 1', 'art 1', 'art 2', 'art 2', 'art 3', 'art 3', 'art 3', 'art 3']

2 The purpose of this form is to obtain information required to assess your claim for the above drug. To be eligible for coverage, the drug must represent reasonable treatment of the disease or injury upon which your claim is based. Approval for coverage of this drug may be reassessed at any time at Great-West Life s discretion. 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. Please print Part 1a Plan Member Information Plan Member: Patient Name: Plan Name: Plan Number: Plan Member I.D. Number: Patient Date of Birth (DD/MM/YYYY): Address (number, street, city, province, postal code): Home Phone Number: ( ) Work Phone Number: ( ) Cell Phone Number: ( ) Please indicate preferred contact phone number and if there are any times when telephone contact with you about your claim would be most convenient. Would you prefer to receive correspondence by ? Yes (te that some correspondence may still need to be sent by regular mail). If yes, provide address: Part 1b Plan Member Information Please attach a current prescription drug history report on the patient. This report can be obtained by your pharmacy. Part 2a Coordination of Benefits Are you currently on, or have you previously been on Tysabri? Yes If Yes, a) indicate start date: (DD/MM/YYYY) b) coverage provided by: (if coverage is not provided by Great-West Life please provide Pharmacy print out showing purchase of Tysabri) Have you applied for coverage or received any financial assistance or other support related to this drug: Under any group benefit plan? If Yes, name of covered family member: Yes Relationship: Name of Insurance Company: Plan number: Plan Member I.D. number: Provide details and attach documentation of acceptance or declination: Under a provincial program or from any other source? Yes If Yes, name of program or other source: Provide details and attach documentation of acceptance or declination: If, please explain why application has not been made: Under a patient assistance program? Yes If Yes, name of program(s): Patient assistance program I.D. number: Patient assistance program contact person name and phone number: Contact name: Phone number: ( ) Are you currently receiving disability benefits for the condition for which this drug has been prescribed? Yes Page 1 of 4 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.
3 Part 2b Patient Assistance Program Information Have you enrolled in the patient assistance program for Tysabri? Yes If Yes, please provide the following information: 1. Has a phone call between the patient assistance program, the plan member and Great-West Life occurred regarding coverage available through your group benefit plan? Yes 2. Patient assistance program patient ID Number: 3. Patient assistance program contact person name and phone number: Contact Name: Phone Number: ( ) At Great-West Life, we recognize and respect the importance of privacy. Personal information that we collect is used for the purposes of assessing eligibility for this drug and for administering the group benefits plan. For a copy of our Privacy Guidelines, or if you have questions about our personal information policies and practices (including with respect to service providers), refer to or write to Great-West Life s Chief Compliance Officer. I authorize Great-West Life, any healthcare provider, my plan administrator, any insurance or reinsurance company, administrators of government benefits or patient assistance programs or other benefits programs, other organizations, or service providers working with Great-West 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 benefits plan. I acknowledge that providing my consent will help Great-West Life to assess my claim and that refusing to consent may result in delay or denial of my claim. This consent may be revoked by me at any time by sending written instruction to that effect. I certify that the information given is true, correct, and complete to the best of my knowledge. Plan Member s signature: Date: Please have Part 3 completed by your prescribing physician. Page 2 of 4
4 Attach extra information if necessary. Part 3 Physician Information (to be completed for all conditions for which Tysabri has been prescribed) te 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. Name of prescribing physician (please print): Specialty: Address (number, street, city, province, postal code): Telephone Number (including area code): Fax Number (including area code): 1. Diagnosis and stage of disease (include date of initial diagnosis): (MM/YYYY) Relapsing-remitting multiple sclerosis Other (please state): 2. Prescribed dosage and frequency: 300mg IV every 4 weeks Other (please specify) and provide rationale: 3. Where will treatment be administered (e.g. in hospital, in physician s office, in clinic, at home)? a) Please provide name of facility b) If this drug will be administered in a hospital, will the patient be treated as an in-patient or out-patient? in-patient out-patient 4. Please provide detailed medical rationale why Tysabri has been prescribed instead of an alternate drug for the management of relapsing-remitting Multiple Sclerosis (MS): 5. What drug(s), past and present, have been prescribed for this condition, including glucocorticoids? Please complete the table below: Drug(s) past and present Dosing Regimen Start Date End Date Patient response to treatment (dd/mm/yyyy) (dd/mm/yyyy) (if discontinued, provide details of intolerance, contraindication, or failure at maximum Page 3 of 4
5 Part 3 Physician Information (continued) Please complete the applicable section(s) below for the condition for which the drug has been prescribed. Relapsing-Remitting Multiple Sclerosis: a) Has patient showed evidence of a significant increase in T2 lesion load compared to a previous MRI scan or at least one gadolinium-enhancing lesion. Yes (include summary of MRI findings) b) Indicate the following levels of disability based on the expanded disability status scale (EDSS): i. At time of diagnosis: ii. With each change of treatment: iii. Current score: Any other condition for which its use has been approved by Health Canada: Please provide any relevant information related to the disease and attach supporting documentation if relevant. Off-label use: Is there evidence supporting the off-label use of this drug? Yes 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. Provide medical rational why Tysabri 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. Drug(s) past and present Dosing Regimen Start Date End Date Patient response to treatment (DD/MM/YYYY) (DD/MM/YYYY) (if discontinued, provide details of intolerance, contraindication, or failure at maximum dose) te for Physician: To be eligible for reimbursement, Great-West Life may require your patient to purchase a drug requiring prior authorization from a pharmacy designated by Great-West Life. If applicable, a health case manager will contact you with further information. I certify that the information provided on this Part 3 is true, correct and complete. Physician s signature: Date: It is important to provide the requested information in detail to help avoid delay in assessing claims for the above drug. The completed Request for Information form can be returned to Great-West Life by mail or fax. Mail to: The Great-West Life Assurance Company Fax to: The Great-West Life Assurance Company Drug Services Fax PO Box 6000 Attention: Drug Services Winnipeg MB R3C 3A5 Page 4 of 4