Fillable Drug Prior Authorization Form Infliximab (Avsola, Inflectra, Remicade, (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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Drug Prior Authorization Form Infliximab (Avsola, Inflectra, Remicade, (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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Page 1 of 10
(Continued on next page)
Plan Member’s signature: Date:
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
M6453(INFLIXIM)-9/20
© The Canada Life Assurance Company, all rights reserved. Canada Life and design are trademarks of The Canada Life Assurance Company.
Any modification of this document without the express written consent of Canada Life is strictly prohibited.
Drug Prior Authorization Form
Infliximab
(Avsola, Inflectra, Remicade, Renflexis)
The purpose of this form is to obtain information required to assess your drug claim.
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.
Canada Life recognizes and respects the importance of privacy. Personal information collected is used for the purposes of
assessing eligibility for this drug and for administering the group benets plan. For a copy of our Privacy Guidelines, or if you have
questions about Canada Life’s personal information policies and practices (including with respect to service providers), refer to
www.canadalife.com or write to Canada Life’s Chief Compliance Ofcer.
I authorize Canada Life, any healthcare provider, my plan administrator, any insurance or reinsurance company, administrators of
government benets or patient assistance programs or other benets programs, other organizations, or service providers working with
Canada 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 benets plan.
I acknowledge that providing consent will help Canada Life to assess my claim and that refusing to consent may result in delay or
denial of my claim. Canada Life reserves the right to audit the information provided on this form at any time and this consent extends
to any audit of my claim. This consent may be revoked by me at any time by sending written instruction to that effect.
I also consent to the use of my personal information for Canada Life and its afliates’ internal data management and analytics purposes.
If the patient is a person other than myself, I conrm that the patient has given their consent to provide their personal information and
for Canada Life to use and disclose it as set out above.
I certify that the information given below is true, correct, and complete to the best of my knowledge. Failure to provide true, correct
and complete information on this form could result in revocation of any approval decision, a requirement to repay paid claims or other
appropriate action.
Form Completion Instructions:
1. Complete “Patient Information” sections.
2. Have the prescribing physician complete the “Physician Information” sections.
3. Send all pages of the completed form to us by mail, fax or email as noted below.
Note: As email is not a secure medium, any person with concerns about their prior authorization form/medical information being
intercepted by an unauthorized party is encouraged to submit their form by other means.
Mail to: The Canada Life Assurance Company
Drug Claims Management
PO Box 6000
Winnipeg MB R3C 3A5
Fax to: The Canada Life Assurance Company
Fax 1-204-946-7664
Attention: Drug Claims Management
Email to: cldrug.services@canadalife.com
Attention: Drug Claims Management
For additional information regarding Prior Authorization and Health Case Management, please visit our Canada Life website at
www.canadalife.com or contact Group Customer Contact Services at 1-800-957-9777. Deaf or hard of hearing and require access to
a telecommunications relay service? Please contact us at 711 for TTY to Voice or 1-800-855-0511 for Voice to TTY.
Page 2 of 10
Infliximab
(Avsola, Inflectra, Remicade, Renflexis)
Plan Member:
Plan Name:
Patient Date of Birth (DD/MM/YYYY):
n n If yes, please provide email address:
Please indicate preferred contact number and if there are any times when telephone contact with you about your claim would be most convenient.
Plan Number:
Address (number, street, city, province, postal code):
Plan Member ID Number:
Patient Name:
– (please print)
n n
If Yes, a) indicate start date (DD/MM/YYYY):
b) coverage provided by:
(if coverage is not provided by Canada Life please provide pharmacy print-out showing purchase of this drug)
n n
If Yes, name of other Insurance Company:
If other plan is with Canada Life, tell us the plan and ID number:
Name of plan member:
Relationship to patient:
Provide details and attach documentation of acceptance or decline:
n n
If Yes, name of program or other source:
Provide details and attach documentation of acceptance or decline:
n n
n n
1. Patient assistance program patient ID Number:
Contact Name: Phone Number:
(Continued on next page)
M6453(INFLIXIM)-9/20
Patient Information
Plan Member Information Complete all sections of this page
May we contact you by email? (Note that some correspondence may still need to be sent by regular mail).
Yes No
Tell us if you have been on this drug before
Is the patient currently on, or previously been on this drug? Yes No
Tell us if you have coverage with any other benefits plan
Does the patient have drug coverage under any other group benets plan? Yes No
Tell us about any Provincial or other coverage you may have
Does the patient have coverage under a provincial program or from any other source? Yes No
Is the patient currently receiving disability benets for the condition for which this drug has been prescribed? Yes No
Tell us about any Patient Assistance Program you might be enrolled in
Has the patient enrolled in the patient assistance program for this drug? Yes No
If Yes, please provide the following information:
2. Patient assistance program contact person name and phone number:
Page 3 of 10
Infliximab
(Avsola, Inflectra, Remicade, Renflexis)
Name of prescribing physician:
Specialty:
Address (number, street, city, province, postal code):
Telephone Number (including area code): Fax Number (including area code):
(please print)
n n n
n n n
n
n n
Provide rationale:
Patient’s weight: kg (for weight-based dosing)
Date determined (MM/YYYY):
Number of vials per treatment requested:
(include date of initial diagnosis)(MM/YYYY):
n n
n n
n n
n
n
3. What is the anticipated duration of treatment with this drug?
n n n n n
5. Please provide medical rationale why this drug has been prescribed instead of an alternate drug in the same therapeutic class:
M6453(INFLIXIM)-9/20
Physician Information
Note 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.
Attach extra information if necessary. GENETIC TEST RESULTS ARE NOT REQUIRED
Physician’s Information
1. Prescribed dosage and regimen:
Drug:
Avsola
Inectra
Remicade
Renexis
Dosage:
3mg/kg
5mg/kg
Other (Please specify):
Regimen:
induction at 0, 2, and 6 weeks then every 8 weeks
every 8 weeks
2. Health Canada Indication
Ankylosing Spondylitis
Crohn’s Disease
Psoriasis
Psoriatic Arthritis
Rheumatoid Arthritis
Ulcerative colitis
Complete questions 1 – 5 and Physician’s information
Other (approved by Health Canada):
Other (prescribed use is not approved by Health Canada):
Complete questions 1 – 6 and Other condition (Health Canada approved)
Complete questions 1 –6 and Off-label use
4. Where will treatment be administered? Home Physician’s Ofce Private clinic Hospital in-patient Hospital out-patient
Page 4 of 10Page 4 of 10
Physician Information
Infliximab
(Avsola, Inflectra, Remicade, Renflexis)
(Continued on next page)
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
Physician’s Information (continued) (please print)
Current BASDAI score and date
(DD/MM/YYYY)
n n
If yes, indicate length and time present:
M6453(INFLIXIM)-9/20
6. Drug and Treatment History – must be completed for other conditions (Health Canada approved) and Off-label use. If coverage for these
drugs was not provided by Canada Life, please submit a pharmacy printout for the last 12 months.
Drug(s) and Treatment(s)
past and present
Dosing Regimen Start Date
(DD/MM/YYYY)
End Date
(DD/MM/YYYY)
Clinical Results/Outcome
Failure Intolerance Other
Failure Intolerance Other
Failure Intolerance Other
Failure Intolerance Other
Ankylosing Spondylitis
Provide diagnostic imaging report of SI joint with interpretation
Back pain present? Yes No
Drug(s) and Treatment(s)
past and present
Dosing Regimen Start Date
(DD/MM/YYYY)
End Date
(DD/MM/YYYY)
Clinical Results/Outcome
Failure Intolerance Other
Failure Intolerance Other
Failure Intolerance Other
Failure Intolerance Other
If coverage for these drugs was not provided by Canada Life, please submit a pharmacy printout for the last 12 months.
Page 5 of 10
n n
Date of admission:
Patient weight in hospital (in kg):
Date of discharge (actual or estimated):
n
n
Date of infusion’s and dosage:
Date of next scheduled dose:
HBI:
MAYO:
Endo Subscore:
Date: (DD/MM/YYYY)
Date: (DD/MM/YYYY)
Date: (DD/MM/YYYY)
n n
Current MAYO: Date:
Endo Subscore: Date:
ESR: Date:
CRP: Date:
n n
Current HBI: Date assessed (DD/MM/YYYY):
n
n
Physician Information
Infliximab
(Avsola, Inflectra, Remicade, Renflexis)
M6453(INFLIXIM)-9/20
Inflammatory Bowel Disease
Has the patient been hospitalized for this condition? Yes No
Was iniximab started while patient was hospitalized? Yes No
Pre-Infusion’s
Ulcerative Colitis
Moderate Severe
For both Ulcerative and Crohn’s Disease provide the following results
and date (DD/MM/YYYY):
Crohn’s Disease: Moderate Severe
Fistulizing Crohn’s disease despite a full and adequate course of therapy with conventional treatment:
Actively draining perianal or enterocutaneous stula(e) with minimal luminal disease activity
Fistulizing CD with concomitant lumina; disease with actively draining perianal or enterocutaneous score ≥7
Page 6 of 10
Inflammatory Bowel Disease (continued)
Physician Information
Infliximab
(Avsola, Inflectra, Remicade, Renflexis)
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
M6453(INFLIXIM)-9/20
Drug(s) and Treatment(s)
past and present
Dosing Regimen Start Date
(DD/MM/YYYY)
End Date
(DD/MM/YYYY)
Clinical Results/Outcome
Corticosteroids
Failure Intolerance Other
5-ASA
Failure Intolerance Other
Methotrexate (MTX)
Failure Intolerance Other
6 - Mercaptopurine (6-MP)
Failure Intolerance Other
Azathioprine (AZA)
Failure Intolerance Other
Antibiotics
Failure Intolerance Other
Failure Intolerance Other
If coverage for these drugs was not provided by Canada Life, please submit a pharmacy printout for the last 12 months.
Page 7 of 10
Physician Information
Infliximab
(Avsola, Inflectra, Remicade, Renflexis)
%BSA Areas of Body involved
Thickness of plaques Current results and date of both of the following (DD/MM/YYYY)
DLQI PASI
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
M6453(INFLIXIM)-9/20
Psoriasis
Drug(s) and Treatment(s)
past and present
Dosing Regimen Start Date
(DD/MM/YYYY)
End Date
(DD/MM/YYYY)
Clinical Results/Outcome
Methotrexate
Failure Intolerance Other
Acitretin
Failure Intolerance Other
Cyclosporine
Failure Intolerance Other
Failure Intolerance Other
Failure Intolerance Other
If coverage for these drugs was not provided by Canada Life, please submit a pharmacy printout for the last 12 months.
Page 8 of 10
Physician Information
Infliximab
(Avsola, Inflectra, Remicade, Renflexis)
Swollen joint count Results of the following and date (DD/MM/YYYY)
ESR: Date:
CRP: Date:
Current results and date of one of the following (DD/MM/YYYY)
CDAI DAS28 HAQ
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
M6453(INFLIXIM)-9/20
Psoriatic Arthritis
Drug(s) and Treatment(s)
past and present
Dosing Regimen Start Date
(DD/MM/YYYY)
End Date
(DD/MM/YYYY)
Clinical Results/Outcome
Methotrexate
Failure Intolerance Other
Leunomide
Failure Intolerance Other
Sulfasalazine
Failure Intolerance Other
Failure Intolerance Other
Failure Intolerance Other
Failure Intolerance Other
If coverage for these drugs was not provided by Canada Life, please submit a pharmacy printout for the last 12 months.
Page 9 of 10
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
n n n
Clinical details:
Please provide any relevant information related to the disease and attach supporting documentation.
Swollen joint count Results of the following and date (DD/MM/YYYY)
ESR: Date:
CRP: Date:
Current results and date of one of the following (DD/MM/YYYY)
CDAI DAS28 HAQ
Physician Information
Infliximab
(Avsola, Inflectra, Remicade, Renflexis)
M6453(INFLIXIM)-9/20
Rheumatoid Arthritis
Drug(s) and Treatment(s)
past and present
Dosing Regimen Start Date
(DD/MM/YYYY)
End Date
(DD/MM/YYYY)
Clinical Results/Outcome
Methotrexate
Failure Intolerance Other
Leunomide
Failure Intolerance Other
Failure Intolerance Other
Failure Intolerance Other
Failure Intolerance Other
Failure Intolerance Other
If coverage for these drugs was not provided by Canada Life, please submit a pharmacy printout for the last 12 months.
Other condition (Health Canada approved)
Page 10 of 10
Date of initial diagnosis (DD/MM/YYYY):
n n
Provide medical rationale why this drug 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 efcacy since previous request.
Physician’s Signature: Date:
License Number:
Physician Information
Infliximab
(Avsola, Inflectra, Remicade, Renflexis)
M6453(INFLIXIM)-9/20
Off-label use
Questions 1-6 must be completed.
Is there clinical evidence supporting the off-label use of this drug? Yes No
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 efcacy; and
• Published recommendations in evidence-based guidelines supporting its use.
Note for Physician: To be eligible for reimbursement, Canada Life may require your patient to purchase a drug requiring prior
authorization from a pharmacy designated by Canada Life. If applicable, a health case manager will contact you with further
information.
I certify that the information provided is true, correct, and complete.
It is important to provide the requested information in detail to help avoid delay in assessing claims for the above drug. This form may
be subject to audit. The completed form can be returned to Canada Life by mail, fax, or email.
Note: As email is not a secure medium, any person with concerns about their prior authorization form/medical information being
intercepted by an unauthorized party is encouraged to submit their form by other means.
Mail to: The Canada Life Assurance Company
Drug Claims Management
PO Box 6000
Winnipeg MB R3C 3A5
Fax to: The Canada Life Assurance Company
Fax 1-204-946-7664
Attention: Drug Claims Management
Email to: cldrug.services@canadalife.com
Attention: Drug Claims Management
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Drug Prior Authorization Form Infliximab (Avsola, Inflectra, Remicade, (Great-West Life Insurance for Personal, Group & Benefits in Canada)

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Completed 24 December 2020

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