Microsoft word - 6504benefit_drugforme.doc

List of covered drugs as of April 1, 2011 U pdated list can be found at plan using the password prescription. You may also obtain a list from Great-West Life at 1-866-716-1313. he Employer reserves the right to change the content of the drug plan list without notice. ( Note: not all strengths and formulations of the drugs listed below are covered.) nortriptyline, paroxetine (paxil) 10mg/20mg/30mg, sertraline typhim vi, vaqta, varilrix, varivax iii, (lipidil), gemfibrozil, lescol, lipitor, bold Italic = requires Prior Authorization form Request for Drug Exception Form (For list of drugs covered – Refer to page 1) In order for your exception to be considered you must have previously tried a covered drug for your medical condition and either the drug was not effective or you have a contraindication to the drug. Use this form to request coverage of a drug that is not automatically covered under your drug plan. Provide the requested information to ensure timely assessment of your claim. Do not use this form for drugs that require PRIOR AUTHORIZATION. Please refer to page one (1) for the list of Prior Authorization drugs which are indicated in bold italics. The Prior Authorization forms can be found at using the password prescription or call Great-West Life at 1-866-716-1313. Plan Number: 51391 – Canada Post Corporation Would you like Great-West Life to contact you by telephone upon completion of the exception review? Yes ❑ No ❑ If yes, please indicate the phone number where they can reach you and leave a message should you be unable to answer: (______)____________ At Great-West Life, we recognize and respect the importance of privacy. Personal information that we collect is used for the purpose of assessing eligibility for this drug and for administering the group benefits plan. I authorize Great-West Life, my physician or healthcare provider, and TELUS Health Solutions to exchange information when necessary for these purposes. Patient/Guardian’s signature: _________________________________________ Date: ______________________________ To obtain coverage for the drug, one other covered pharmacotherapy must have been tried in the past, unless contraindication exists. What is the health condition being treated with this drug? Is the drug prescribed to treat a health condition for which the specific drug use is approved by Health Canada? Yes ❑ No ❑ Did the patient previously try a medication (pharmacotherapy) to treat this health condition? Yes ❑ No ❑ If yes, list the specific names of other medications (pharmacotherapies) used to treat the health condition? If no other medication (pharmacotherapy) was tried, please explain why this drug must be prescribed (for example a contraindication resulting from an allergy reaction): Physician’s signature: __________________________________ Once completed, the Request for Drug Exception Form can be returned to Great-West Life at the address or fax number below.


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