Fillable PRIOR AUTHORIZATION REQUEST (Desjardins Insurace)

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PRIOR AUTHORIZATION REQUEST (Desjardins Insurace)

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10114E (2020-06)
Page 1 of 3




 


GROUP INSURANCE – HEALTH CLAIMS

PRIOR AUTHORIZATION REQUEST
NINLARO (IXAZOMIB)
POMALYST (POMALIDOMIDE)
REVLIMID (LENALIDOMIDE)



PLEASE READ THE INSTRUCTIONS ON THE LAST PAGE OF THIS FORM.
     
  
   
 
Signature of physician: Date:
               





Signature of member:
Date:
Last name and rst name of parent/legal guardian (if applicable):
Signature of paent or parent/legal guardian (if applicable): Date:
  
  
  
   
   
 
YYYY MM DD
Yes
No
If so
  
PATIENT SUPPORT
PROGRAM


A
PATIENT IDENTIFICATION


g
PRIVATE PLAN
Yes  Copy aached to this form.

 
No

PROVINCIAL PLAN
g
Yes Copy aached to this form.
No

B
DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION
Coordinaon of benets: If the paent has coverage under a private insurance plan or is enrolled in a provincial drug insurance plan, please submit the request to this
plan rst. Then send us a copy of the decision noce and this form lled out by the physician, so we can analyze the request.
C
ATTENDING PHYSICIAN SECTION









CONTINUED ON THE BACK
PRINT
NEW REQUEST
C
ATTENDING PHYSICIAN SECTION


• Make sure to ll out all secons so we can process the request faster. If any informaon is missing, we will send the form back to the member.
• In order to consider any diagnosis not menoned on this form, we need supporng documents (clinical pracce guidelines, clinical studies, etc.) that jusfy the drug’s
use in the given context.
PRIOR MEDICATION OR TREATMENT
  


YYYY MM DD
MEDICATION OR TREATMENT NAME
OUTCOME








  

  



  
  
TREATMENT PERIOD








YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
YYYY MM DD
Page 2 of 3
Diagnosis:
 

Informaon relang to anemia caused by a myelodysplasc syndrome
     

        
        
 
     
Informaon relang to mulple myeloma
  
  
  

Prescripon renewal
Anemia due to myelodysplasc syndrome




 



Mulple myeloma
  
Note: 

• 
• 
• 
• 


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






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






•  






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D
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Completed 9 February 2021

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