Page 1 of 2 12553E (2020-04) PRIOR AUTHORIZATION REQUEST KEYTRUDA (PEMBROLIZUMAB) OPDIVO (NIVOLUMAB) YERVOY (IPILIMUMAB) C. P. 3950 Lévis (Québec) G6V 8C6 Fax: 418-838-2134 1-877-838-2134 GROUP INSURANCE - HEALTH CLAIMS 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. Desjardins Insurance life health rerement logo 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 ( ) - ( ) - 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: g Informaon about your diagnosis should be provided by your aending physician. Therefore this secon is non fillable online. Is the paent enrolled in a paent support program? PATIENT SUPPORT PROGRAM Has a request for reimbursement been submied under your provincial plan? PROVINCIAL PLAN Since the response to this request includes confidenal informaon, please indicate how you would like to be informed of the decision: A - PATIENT’S IDENTIFICATION TO BE COMPLETED BY THE MEMBER. Drug name Formulaon Strength Dosage Paent’s weight Scheduled duraon of treatment The paent is receiving or will receive the treatment in a hospital seng: Yes No 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. Unresectable or metastac melanoma: We are not accepng requests for treatment combining Opdivo and Yervoy for this diagnosis. Unresectable or BRAF V600 metastac melanoma: We are not accepng requests for Opdivo for this diagnosis. Ocular melanoma: We are not accepng requests for Opdivo for this diagnosis Informaon relang to unresectable or metastac BRAF V600 wild-type or mutated melanoma - Is the disease advanced or metastac (stage III or IV)? Yes No - Does the paent show brain metastases? Yes No If yes, are the metastases stable? Yes No (Note: Is meant by stable that there is no growth or new lesions suggesng progression.) - ECOG performance status: Diagnosis Unresectable or metastac BRAF V600 wild-type melanoma Non-small cell lung carcinoma Unresectable or metastac BRAF V600 mutated melanoma Metastac renal cell carcinoma Metastac squamous cell carcinoma of the head and neck Other therapeuc indicaon(s) - Please specify: 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
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Page 1 of 212553E (2020-04)
PRIOR AUTHORIZATION REQUEST KEYTRUDA (PEMBROLIZUMAB) OPDIVO (NIVOLUMAB)
YERVOY (IPILIMUMAB)
C. P. 3950Lévis (Québec) G6V 8C6Fax: 418-838-2134 1-877-838-2134
GROUP INSURANCE - HEALTH CLAIMS
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.
Desjardins Insurance life health retirement logo
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
( ) - ( ) -
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:
g
Information about your diagnosis should be provided by your attending physician. Therefore this section is non fillable online.
Is the patient enrolled in a patient support program?PATIENT SUPPORT PROGRAM
Has a request for reimbursement been submitted under your provincial plan?PROVINCIAL PLAN
Since the response to this request includes confidential information, please indicate how you would like to be informed of the decision:
A - PATIENT’S IDENTIFICATION TO BE COMPLETED BY THE MEMBER.
Drug name Formulation Strength Dosage Patient’s weight Scheduled duration of treatment
The patient is receiving or will receive the treatment in a hospital setting: Yes No
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.
Unresectable or metastatic melanoma: We are not accepting requests for treatment combining Opdivo and Yervoy for this diagnosis.Unresectable or BRAF V600 metastatic melanoma: We are not accepting requests for Opdivo for this diagnosis. Ocular melanoma: We are not accepting requests for Opdivo for this diagnosis
Information relating to unresectable or metastatic BRAF V600 wild-type or mutated melanoma
- Is the disease advanced or metastatic (stage III or IV)? Yes No
- Does the patient show brain metastases? Yes No
If yes, are the metastases stable? Yes No (Note: Is meant by stable that there is no growth or new lesions suggesting progression.)
- ECOG performance status:
Diagnosis Unresectable or metastatic BRAF V600 wild-type melanoma Non-small cell lung carcinoma Unresectable or metastatic BRAF V600 mutated melanoma Metastatic renal cell carcinoma Metastatic squamous cell carcinoma of the head and neck Other therapeutic indication(s) - Please specify:
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
Page 2 of 2
C - ATTENDING PHYSICIAN’S SECTION (CONTINUED)
YYYY MM DD YYYY MM DD
- 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)
Information relating to non-small cell lung carcinoma- The disease is: Advanced (Stage III) Metastatic (Stage IV)
- Will the treatment be administered as monotherapy? Yes No
- Does the tumour express PD-L1? Yes No Please provide the Tumour Proportion Score (TPS): %
- Does the patient show a rearrangement of the ALK gene? Yes No
- Does the patient show activating mutations of EGFR? Yes No
- Does the patient show brain metastases? Yes No
If yes, are the metastases stable? Yes No (Note: Is meant by stable that there is no growth or new lesions suggesting progression.)
- ECOG performance status:
Information relating to metastatic renal cell carcinoma or metastatic squamous cell carcinoma of the head and neck- Does the patient show brain metastases? Yes No
If yes, are the metastases stable? Yes No (Note: Is meant by stable that there is no growth or new lesions suggesting progression.)
- ECOG performance status:
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.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
or by mail to Desjardins Insurance, Group Insurance, Health Claims Postal code 3 9 5 0, Lévis Québec G 6 V 8 C 6
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
Prescription renewalPlease provide objective evidence of efficacy:
ECOG performance status:
Medication or treatment Dose Start date End date Outcome name (provide details of intolerance, contraindication or failure)
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:
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.
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