Prior authorization request Botox 10122E · PRIOR AUTHORIZATION REQUEST Fax: BOTOX...
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Page 1 of 2 10122E (2018-07) PRIOR AUTHORIZATION REQUEST BOTOX (ONABOTULINUMTOXINA) C. P. 3950 Lévis (Québec) G6V 8C6 Fax: 418-838-2134 1-877-838-2134 GROUP INSURANCE - HEALTH CLAIMS All the informaon I have provided on the claim form is accurate and complete. I authorize Desjardins Financial Security Life Assurance Company, hereinaſter Desjardins Insurance, strictly for the purposes of managing my file and seling this claim to: (a) collect from any person or legal enty, or from any public or parapublic organizaon, only the informaon deemed necessary to manage my file. The non-exhausve list of sources from which informaon may be collected includes health care professionals or facilies, insurance companies; (b) communicate to the said persons or organizaons only the personal informaon about me that is deemed necessary for the purposes of my file; (c) when necessary use the personal informaon it may have about me in exisng files that are now closed. This authorizaon is also valid for the collecon, use and communicaon of personal informaon concerning my dependents, insofar as applicable to the claim. A photocopy of this authorizaon is as valid as the original. Signature of member Date Last name and first name of parent/legal guardian (if necessary) Signature of paent or parent/legal guardian (if necessary): Date: B - DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION Please read the instrucons on the back of this form and complete the enre form. If any informaon is missing, the form will be returned to the member. Paent’s last name and first name Relaonship with member Date of birth of paent Member Spouse Dependent child Member’s last name and first name Contract no. Cerficate no. No., street, apt. City Province Postal code Telephone nos: Home: Office: Extension: By fax: ( ) - By mail (The response to your request will be sent to the address indicated in this secon.) YYYY MM DD ( ) - ( ) - PROVINCIAL PLAN Yes - Please provide a copy of the noce of approval or refusal. Copy aached to this form. No - Please explain: Yes No If so - Program name: - Contact person: Telephone no.: ( ) - Extension: PATIENT SUPPORT PROGRAM g Has a request for reimbursement been submied under your provincial plan? Is the paent enrolled in a paent support program? Since the response to this request includes confidenal informaon, please indicate how you would like to be informed of the decision: Desjardins Insurance life health rerement logo A - PATIENT’S IDENTIFICATION TO BE COMPLETED BY THE MEMBER. Drug name Formulaon Strength Dosage Scheduled duraon of treatment The paent is receiving or will receive the treatment in a hospital seng: Yes No Diagnosis Cervical dystonia Blepharospasm Strabismus Severe axillary hyperhidrosis Equinus foot Chronic migraines Neurogenic detrusor overacvity associated with a neurological condion Overacve bladder Other severe spascity condion(s) - Please specify: Other therapeuc indicaon(s) - Please specify: Physician’s last name and first name (PLEASE PRINT) License no. Speciality No., street, office City Province Postal code Telephone no.: Fax no.: Signature of physician: Date: ( ) - ( ) - C - ATTENDING PHYSICIAN’S SECTION TO BE COMPLETED BY THE ATTENDING PHYSICIAN. Informaon about your diagnosis should be provided by your aending physician. Therefore this secon is not accessible. Informaon relang to chronic migraines - Number of days with headaches within a month: / month - Duraon of the headaches: hours/day Informaon relang to overacve bladder - Please check the paent’s symptoms: Urgency Dayme urinary frequency Urge urinary inconnence Stress urinary inconnence
Transcript of Prior authorization request Botox 10122E · PRIOR AUTHORIZATION REQUEST Fax: BOTOX...
Page 1 of 210122E (2018-07)
PRIOR AUTHORIZATION REQUEST BOTOX (ONABOTULINUMTOXINA)
C. P. 3950Lévis (Québec) G6V 8C6Fax: 418-838-2134 1-877-838-2134
GROUP INSURANCE - HEALTH CLAIMS
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:
B - DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION
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.
Patient’s last name and first name Relationship with member Date of birth of patient
Member Spouse Dependent childMember’s last name and first name Contract no. Certificate no.
No., street, apt. City Province Postal code
Telephone nos: Home: Office: Extension:
By fax: ( ) - By mail (The response to your request will be sent to the address indicated in this section.)
YYYY MM DD
( ) - ( ) -
PROVINCIAL PLAN Yes - Please provide a copy of the notice of approval or refusal. Copy attached to this form.
No - Please explain: Yes NoIf so - Program name: - Contact person: Telephone no.: ( ) - Extension:
PATIENT SUPPORT PROGRAM
gHas a request for reimbursement been submitted under your provincial plan?
Is the patient enrolled in a patient support program?
Since the response to this request includes confidential information, please indicate how you would like to be informed of the decision:
Desjardins Insurance life health retirement logo
A - PATIENT’S IDENTIFICATION TO BE COMPLETED BY THE MEMBER.
Drug name Formulation Strength Dosage Scheduled duration of treatment
The patient is receiving or will receive the treatment in a hospital setting: Yes No
Diagnosis
Cervical dystonia Blepharospasm Strabismus Severe axillary hyperhidrosis Equinus foot Chronic migraines
Neurogenic detrusor overactivity associated with a neurological condition Overactive bladder
Other severe spasticity condition(s) - Please specify:
Other therapeutic indication(s) - Please specify:
Physician’s last name and first name (PLEASE PRINT) License no. Speciality
No., street, office City Province Postal code
Telephone no.: Fax no.:
Signature of physician: Date:
( ) - ( ) -
C - ATTENDING PHYSICIAN’S SECTION TO BE COMPLETED BY THE ATTENDING PHYSICIAN.
Information about your diagnosis should be provided by your attending physician. Therefore this section is not accessible.
Information relating to chronic migraines
- Number of days with headaches within a month: / month - Duration of the headaches: hours/day
Information relating to overactive bladder
- Please check the patient’s symptoms: Urgency Daytime urinary frequency
Urge urinary incontinence Stress urinary incontinence
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C - ATTENDING PHYSICIAN’S SECTION (CONTINUED)
Information relating to neurogenic detrusor overactivity- Is the detrusor overactivity associated with multiple sclerosis? Yes No - Is the detrusor overactivity associated with subcervical spinal cord injury? Yes No
or by mail to Desjardins Insurance, Group Insurance, Health Claims Postal code 3 9 5 0, Lévis Québec G 6 V 8 C 6
by fax to Desjardins Insurance Group Insurance Health Claims 4 1 8 8 3 8 2 1 3 4 or toll free 1 8 7 7 8 3 8 2 1 3 4
- by mail: Desjardins Insurance Group Insurance, Health Claims C. P. 3950, Lévis (Québec) G6V 8C6
- by fax: Desjardins Insurance Group Insurance, Health Claims, 418-838-2134 or 1-877-838-2134 (toll free)
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.
1. Complete sections A and B. 2. 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. 3. 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.4. Send form:
INSTRUCTIONS - HOW TO COMPLETE AND RETURN THIS FORM
Prior medication or treatmentHas the patient ever used medication or received treatment for this condition? Yes No
If not, please explain: If so, please list the medication or treatment already used for this disease:
Prescription renewal
Please provide objective evidence of efficacy:
In the case of chronic migraines, please provide the number of headaches per month after treatment:
In the case of severe axillary hyperhidrosis, please provide the following information:
- Decrease in sudation: Yes No
Please describe the beneficial effects observed:
- Improvement on the functional and psychosocial levels: Yes No
Please describe the beneficial effects observed:
YYYY MM DD YYYY MM DD
Medication or treatment Dose Start date End date Outcome name (provide details of intolerance, contraindication or failure)
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.
Information relating to severe axillary hyperhidrosis
- Please specify the degree of impairment on the functional and psychosocial levels: Mild Moderate Severe
- Please describe the impairment observed:
