Esdnl.ca

PRESCRIPTION DRUGS
SPECIAL AUTHORIZATION REQUEST
SEE BACK OF FORM FOR PROCEDURES
• Please complete entire form. If information is missing from the form it will be returned to the member.
• Incomplete forms cannot be processed.
• Any costs associated with the completion of this form or obtaining additional medical information are the responsability of the member.
PATIENT INFORMATION (To be completed by the member)
Have you already purchased your prescriptions requested by your physician below? If yes, please attach your paid-in-full receipt.
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, 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
Signature of insured dependent aged 16 and over
DRUGS REQUESTED FOR SPECIAL AUTHORIZATION
For injectables, facility where medication is administered Results from previous treatment
Relevant Lab Test Results
If the products requested are in one of the categories below, please complete the applicable section in addition to the above.
MIGRAINE
PROTON PUMP INHIBITORS
Results:
Have Pariet and Generic Omeprazole been tried? Results:
Results:
Results:
For Renewals:
Response to treatment
REMICADE, ENBREL, KINERET
ANGIOTENSIN RECEPTOR BLOCKERS
ALZHEIMER’S DISEASE TREATMENT
For Renewals:
Response to treatment
BISPHOSPHONATES
MULTIPLE SCLEROSIS
ANTIEMETICS
For Renewals:
Please note: This is not a request to have procedures completed, but to provide results if they have previously been completed.
PHYSICIAN INFORMATION
Physician Last Name and First Name (PLEASE PRINT)
Signature of physician
PROCEDURES FOR SPECIAL AUTHORIZATION
· Special Authorization is a pre-approval process to determine if certain products will be reimbursed under your benefit plan.
· Eligible prescriptions must be purchased in a public pharmacy.
· Special authorization coverage is contingent on your continued status as a Desjar- dins Financial Security (DFS) cardholder or beneficiary.
· To be considered for reimbursement, please submit your original paid receipt to This form must be completed by your attending physician and forwarded to: Desjardins Financial Security
P.O. Box 4358 Station A
Toronto ON M5W 3M3
Upon receipt, the request will be confidentially reviewed according to payment criteria developed by DFS in consultation with health care consultants. In some cases, ad-ditional diagnostic or clinical information may be required. DFS will send you a written response.
Special Authorization may be limited to a specified time period and/or quantity of medi-cation. Renewal of the Special Authorization will be considered by DFS upon request from the member. The renewal request should include information from the physician supporting continued use of the medication.
If the information on your form is complete, the usual turnaround time for assessment is seven to 10 working days. In cases where you require an urgent response due to a medical condition, every effort will be made to respond the same day. If you wish to have a response faxed back to you, request this in writing on your Special Authoriza-tion form. If you wish to know the status of your Special Authorization request, please call our Customer Service Centre at 1-877-838-7763.
NOTE TO PHYSICIAN
Under the Special Authorization program, DFS grants approval for payment of certain benefits if they fall within certain established criteria. By denying a request for Special Authorization, DFS is denying payment for a product and is not challenging the medi-cal opinion of the physician nor rendering a medical opinion.

Source: http://www.esdnl.ca/employment/benefits/forms/drug_authorization_form.pdf