Download prior authorization request

C. P. 3950
Lévis (Québec) G6V 8C6
Fax: 418-838-2134
1-877-838-2134
GROUP INSURANCE - HEALTH CLAIMS
PRIOR AUTHORIZATION REQUEST
CANCER DRUGS
Please read the instructions on the back of this form and complete the entire form. If any information is missing, the form will be returned to the member.
A - PATIENT’S IDENTIFICATION TO BE COMPLETED BY THE MEMBER.
Patient’s last name and first name Relationship with member
Member’s last name and first name
Member
No., street, apt.
Spouse
Contract no.
Date of birth of patient
YYYY
MM
Dependent child
Certificate no.
City
Province
DD
Postal code
)
)
Telephone nos: Home: (
Office: (
Extension:
Since the response to this request includes confidential information, please indicate how you would like to be informed of the decision:
By fax: ( )
-
By mail (The response to your request will be sent to the address indicated in this section.)
PROVINCIAL PLAN
Has a request for reimbursement been submitted under your provincial plan?
Yes - Please provide a copy of the notice of approval or refusal.
Copy attached to this form.
g
No - Please explain:
PATIENT SUPPORT
PROGRAM
Yes
Is the patient enrolled in a patient support program?
No
If so - Program name:
- Contact person: Telephone no.: (
)
-
Extension:
B - DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION
All the information I have provided on the claim form is accurate and complete. I authorize Desjardins Financial Security Life Assurance Company, hereinafter Desjardins
Insurance, strictly for the purposes of managing my file and settling this claim to: (a) collect from any person or legal entity, or from any public or parapublic organization, only
the information deemed necessary to manage my file. The non-exhaustive list of sources from which information may be collected includes health care professionals or facilities,
insurance companies; (b) communicate to the said persons or organizations only the personal information about me that is deemed necessary for the purposes of my file; (c)
when necessary use the personal information it may have about me in existing files that are now closed. This authorization is also valid for the collection, use and communication
of personal information concerning my dependents, insofar as applicable to the claim. A photocopy of this authorization is as valid as the original.
Signature of member
Date
Last name and first name of parent/legal guardian (if necessary)
Signature of patient or parent/legal guardian (if necessary): Date:
C - ATTENDING PHYSICIAN’S SECTION TO BE COMPLETED BY THE ATTENDING PHYSICIAN.
Physician’s last name and first name (PLEASE PRINT)
License no.
No., street, office
Telephone no.: (
Speciality
City
)
-
Province
Fax no.:
(
)
Postal code
-
Signature of physician:
Date:
Drug name
Formulation
Strength
Dosage
Yes
No
The patient is receiving or will receive the treatment in a hospital setting: Patient’s weight
Scheduled duration of treatment
Diagnosis
Avastin:
Bosulif:
Metastatic colorectal cancer (MCRC)
Malignant glioma (WHO grade IV)
Locally advanced, metastatic or recurrent non-small-cell lung cancer (NSCLC)
Platinum-sensitive recurrent epithelial ovarian, fallopian tube and primary peritoneal cancer
Platinum-resistant recurrent epithelial ovarian, fallopian tube and primary peritoneal cancer
Philadelphia chromosome positive chronic myelogenous leukemia in chronic, accelerated or blast phase
Caprelsa:
Symptomatic or progressive medullary thyroid cancer
- Is the patient eligible to the Caprelsa restricted distribution program? Cotellic:
Unresectable or metastatic melanoma with BRAF V600 mutation
- Was the BRAF V600 mutation status identififed with a validated test? As monotherapy
Yes
No
Please specify:
Cyramza:
Gastric cancer
In combination with paclitaxel
- ECOG performance status:
Fludara:
Chronic lymphocytic leukemia (CLL)
Gazyva:
Chronic lymphocytic leukemia
Gleevec:
Advanced hypereosinophilic syndrome (HES) and/or chronic eosinophilic leukemia (CEL)
Dermatofibrosarcoma Protuberans (DFSP)
Myelodysplastic/myeloproliferative diseases (MDS/MPD)
Chronic myeloid leukemia (CML)
Inoperable, recurrent or metastatic gastrointestinal stromal tumour (GIST)
Newly diagnosed acute lymphoblastic leukemia
Acute, resistant or recurrent lymphoblastic leukemia
Gastrointestinal stromal tumour with high risk of recurrence
Aggressive sub-types of systemic mastocytosis Slow-growing non-Hodgkin’s lymphoma or Waldenström’s macroglobulinemia
Hycamtin: Small cell lung cancer
Ibrance:
HER2-negative advanced breast cancer
- Is Ibrance administered as initial endocrine-based therapy for the metastatic disease? Yes
No
- Is the patient post-menopausal?
Yes
No
- ECOG performance status:
Iclusig:
Imbruvica:
Chronic myeloid leukemia
Metastatic carcinoma of the ovary
- Neutrophil count:
Philadelphia chromosome positive acute lymphoblastic leukemia
Chronic lymphocytic leukemia - Does the patient show a 17p deletion?
Yes
Relapsed or refractory mantle cell lymphoma
Waldenström’s macroglobulinemia
- ECOG performance status:
No
Inlyta: Metastatic renal cell carcinoma - Has the patient had treatment failure with a tyrosine kinase inhibitor?
Yes
- Has the patient had treatment failure with a cytokine?
Yes
No - Is this a clear cell carcinoma?
10119E (16-12)
/L)
No
Yes
No
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C - ATTENDING PHYSICIAN’S SECTION
(CONTINUED)
Diagnosis (continued)
Nexavar:
Unresectable hepatocellular carcinoma (HCC)
Locally advanced or metastatic renal cell carcinoma
Locally advanced or metastatic differentiated thyroid carcinoma - Is the disease in progression?
Sprycel:
Chronic phase and accelerated phase myeloid leukemia (CML)
Philadelphia chromosome positive chronic myeloid leukemia
Sutent:
Gastrointestinal stromal tumour
Pancreatic neuroendocrine tumour
Metastatic renal adenocarcinoma : Is the carcinoma of clear cell histology?
Yes
- Patient’s ECOG* performance status:
Tagrisso:
Non-small cell lung cancer
- Is the patient EGFR T790M mutation-positive?
Tarceva:
Non-small cell lung cancer (second line therapy)
Non-small cell lung cancer (as monotherapy for maintenance treatment)
Non-small cell lung cancer (as monotherapy for first-line treatment)
Tasigna:
Chronic phase and accelerated phase myeloid leukemia (CML)
First-line treatment of chronic myeloid leukemia in chronic phase
Temodal: Anaplastic astrocytoma
Glioblastoma multiforme (GBM) - Will the treatment be administered in combination with radiotherapy? Malignant melanoma with brain metastases
Yes
No
*ECOG = Eastern Cooperative Oncology Group
Yes
No
- Patient’s ECOG performance status:
}
Patient’s ECOG performance status:
Philadelphia chromosome positive chronic myeloid leukemia
Tykerb: Metastatic breast cancer whose tumor overexpresses HER2
- Menopausal woman:
Yes
No
- Patient’s ECOG performance status:
- Is the cancer hormone receptor positive?
- Candidate to Herceptin (trastuzumab): - Candidate for hormone therapy:
Yes
No
Votrient:
Xalkori:
Xtandi:
Metastatic renal cell (clear cell carcinoma) (MRCC)
Adult patient with selective subtypes of advanced Soft Tissue Sarcoma
- Patient’s ECOG performance status:
- The patient is:
Zelboraf: BRAF V600 mutation-positive unresectable or metastatic melanoma Zolinza:
Advanced cutaneous T-cell lymphoma (CTCL)
Zydelig:
Relapsed chronic lymphocytic leukemia
Yes
Yes
No
No
- In association with:
Advanced or metastatic non-small cell lung cancer
Does the tumor show a rearrangement of the ALK gene?
Metastatic prostate cancer: Is the cancer castration-resistant?
Asymptomatic
No
first line therapy
Yes
Yes
No
No
Letrozole Yes
No
Capecitabine
second line therapy
- Patient’s ECOG performance status:
Mildly asymptomatic
- Will the treatment be administered in combination with Rituximab? Follicular lymphoma
Symptomatic
- Patient’s ECOG performance status:
Yes No
Yes
No
Prior medication or treatment
Has the patient ever used medication or received treatment for this condition? If not, please explain:
If so, please list the medication or treatment already used for this disease:
Médication or treatment
Dose
Start date End date
name
YYYY
YYYY
MM DD
MM DD
Outcome (provide details of intolerance, contraindication or failure)
Prescription renewal
Please provide objective evidence of efficacy:
The drug may be eligible for reimbursement only if it meets the insurer’s criteria, if it is not administered in a hospital setting and if it is not covered under a provincial
drug insurance plan or a government program.
If you are enrolled in a provincial drug insurance plan, please submit your claim to this plan first since it may cover this drug. If your claim is refused by your provincial drug
insurance plan, please send us a copy of the notice of refusal and the form completed by your physician so that we can analyze your file.
INSTRUCTIONS - HOW TO COMPLETE AND RETURN THIS FORM
1.
2.
3.
4.
Complete sections A and B.
Ask your physician to complete section C. The member is responsible for assuming any costs incurred to complete this form or to obtain
additional information.
To obtain a reimbursement once the drug has been approved, please use your Express Scripts Canada card at the pharmacy or submit your original receipts by mail.
Eligible drugs must be dispensed by a pharmacist or a physician, if there is no pharmacist.
Send form:
- by fax: Desjardins Insurance
- by mail: Desjardins Insurance
Group Insurance, Health Claims,
Group Insurance, Health Claims
418-838-2134 or 1-877-838-2134 (toll free)
C. P. 3950, Lévis (Québec) G6V 8C6
Under its prior authorization program, Desjardins Insurance approves the payment of certain claims that meet criteria established jointly with healthcare consultants.
If the information on your form is complete, your request will normally be processed within 5 business days. When the request form is received, it will be assessed in the
strictest confidence. In some situations, additional diagnostic or clinical information may be required.
If the treatment continues beyond the authorized period, you will be asked to submit a new request form and provide information that justifies the extension of treatment. If
you have an Express Scripts Canada card, your pharmacist will be advised that the authorization period is coming to an end.
The insurance must be in force and the patient still covered at the date expenses are incurred. This prior authorization is subject to change if, at the time expenses are incurred,
the contract has been modified.
When a prior authorization is rejected, it means that Desjardins Insurance refuses to pay for a product. It is not an indication that Desjardins Insurance is challenging the
opinion of the physician.
If you have any questions, please contact our Customer Contact Centre.
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