13175E02 (2020-02)
REQUEST FOR REIMBURSEMENT OF A MEDICATION NOT INCLUDED IN THE


Desjardins Insurance life health rerement logo
M
F
M
F
YYYY MM DD
YYYY MM DD
Name of policyholder Group no. Cercate no.
Last name and rst name of member Sex Date of birth
Address - No., street, apt. City Province Postal code
Last name and rst name of paent Sex Date of birth
Relaonship to member DIN (Drug Idencaon Number)
All the informaon I have provided on the claim form is accurate and complete. I acknowledge having read the Personal Informaon Management secon. I authorize
Desjardins Insurance strictly for the purposes of managing my le and seling this claim to: (a) collect from any person or legal enty, or from any public or parapublic
organizaon, only the informaon deemed necessary to manage my le. The non-exhausve list of sources from which informaon may be collected includes healthcare
professionals or facilies, insurance companies; (b) communicate to the said persons or organizaons only the personal informaon about me that is deemed necessary
for the purposes of my le; (c) when necessary, use the personal informaon it may have about me in exisng les that are now closed. This authorizaon is also valid for
the collecon, use and communicaon of personal informaon concerning my dependents, insofar as applicable to the claim. A photocopy of this authorizaon is as valid
as the original.
Signature of member
Date
Signature of insured
 
Desjardins Financial Security Life Assurance Company, hereinaer Desjardins Insurance, handles the personal informaon it has on you in a condenal manner. Desjardins
Insurance keeps this informaon on le so that you may benet from group insurance services oered by the Company. This informaon is consulted solely by Desjardins
Insurance employees who need to do so in the course of their work. Desjardins Insurance may compile anonymized personal informaon for stascal and informaonal
purposes. Desjardins Insurance may also communicate with plan members to provide them with opmal health management. You have the right to consult your le. You may
also have informaon corrected if you demonstrate that it is inaccurate, incomplete, ambiguous or not useful. To do so, you must send a wrien request to the following address:
Privacy Ocer, Desjardins Insurance, 200, rue des Commandeurs, Lévis, Québec, G6V 6R2. Desjardins Insurance may use the client list to oer its clients an insurance product
following the terminaon of their group insurance. If you do not wish to receive these oers, you may have your name removed from the list. To do so, you must send a wrien
request to the Privacy Ocer at Desjardins Insurance.

Any charges for the compleon of this form are the members responsibility.
The member must complete secons A and C.
If the request is for the reimbursement of a medicaon that is not included in the er-1 managed formulary, the aending physician must complete secons D and F.
If the request is for the reimbursement of a brand name medicaon, the aending physician must complete secons E and F. The member must have read and
understood the instrucons provided in these secons.
This request will be assessed based on the medical informaon provided and may be reviewed by our physician or pharmacist.
IMPORTANT INFORMATION
A PATIENT'S IDENTIFICATION 
B 
C DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION
Address C. P. 3950 Lévis Québec G 6 V 8 C 6 web site desjardins life insurance dot com slash plan member Telephone 1 8 0 0 2 6 3 1 8 1 0
C. P. 3950
Lévis (Québec) G6V 8C6
desjardinslifeinsurance.com/planmember
Tel.: 1-800-263-1810
Fax: 418-838-2134 or 1-877-838-2134
PRINT
NEW REQUEST


Please send form by fax: 4 1 8 8 3 8 2 1 3 4 toll free: 1 8 7 7 8 3 8 2 1 3 4 or by mail: Desjardins Insurance CP 3950 Lévis Québec G 6 V 8 C 6
The medicaon for which you are applying for an excepon is not included in the er-1 managed formulary and is currently covered at a lower percentage. If this
excepon is approved, the medicaon will be covered at a higher percentage.
The excepon will only be approved if the aending physician provides an acceptable medical reason that explains why the paent is unable to take a therapeuc
alternave listed in the er-1 managed formulary.
The approved medicaon will be covered up to the lowest cost generic equivalent available on the market. If the paent cannot take the generic equivalent either,
another acceptable medical reason will need to be provided in secon E.
E BRAND NAME MEDICATION
 
The brand name medicaon for which you are applying for an excepon is currently covered up to the lowest cost generic equivalent available on the market. If this
excepon is approved, the medicaon will be covered at the price provided for the brand name medicaon.
The excepon will only be approved if the aending physician provides an acceptable medical reason to support why the paent is unable to take the lowest cost
generic equivalent available on the market.
1. What is the paent's diagnosis?
2. Brand name drug requested:
Name and strength: DIN:
Dosage:
3. Generic drug tried:
Name and strength: DIN:
Dosage: Treatment period: From To
4. What is the medical reason for the request: Allergies Adverse reacon Therapeuc failure Other:
The eects aributable to the adverse or allergic reacon are:
Mild (no intervenon required) Moderate (minimal intervenon required) Severe (hospitalizaon required) Life threatening
Please describe the adverse or allergic reacon observed (nature, extent, severity):
1. What is the paent's diagnosis?
2. Drug requested:
Name and strength: DIN:
Dosage:
3. Alternave drug listed in the er-1 managed formulary that the paent has tried:
Name and strength: DIN:
Dosage: Treatment period: From To
4. What is the medical reason for the request: Allergies Adverse reacon Therapeuc failure Other:
The eects aributable to the adverse or allergic reacon are:
Mild (no intervenon required) Moderate (minimal intervenon required) Severe (hospitalizaon required) Life threatening
Please describe the adverse or allergic reacon observed (nature, extent, severity):
D 

( ) -
( ) -
Last name and rst name of physician (PLEASE PRINT)
Address - No., street, suite City Province Postal code
Telephone no.: Fax no.:
 
F  IDENTIFICATION 