Form Gl2404 - Group Benefits Prior Authorization - Fampyra - 2014

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GROUP BENEFITS

PRIOR AUTHORIZATION FORM

FAMPYRA

INSTRUCTIONS

Mail: Co-operators Life Insurance Company

Extended Health Care Claims

1920 College Avenue

Regina, SK S4P 1C4

Fax:

(306) 761-7101

PART 1 - PATIENT INFORMATION

Group __________________________________

Account _______________________________________ Certificate _____________________________________

Plan Member ___________________________________________________________ ________ _________________________________________________________

First Name

Initial

Last Name

Patient _________________________________________________________________ ________ _________________________________________________________

First Name

Initial

Last Name

Address _______________________________________________________ ____________________________________________ ____________ ________________

Street

City

Province

Postal Code

Date of Birth ____________________________

Relationship to Plan Member _______________________________________________________________________

MMM/DD/YYYY

PART 2 - PHYSICIAN INFORMATION

Physician ____________________________________ ________ _______________________________________

Specialty __________________________________

First Name

Initial

Last Name

Address _______________________________________________________ ____________________________________________ ____________ ________________

Street

City

Province

Postal Code

Telephone Number ( ________ ) __________________________ Fax Number ( ________ ) __________________________

Name of Requested Drug _________________________________________________ DIN _________________________

Strength _________________________

Expected Duration of Therapy _____________________________________________ Anticipated Monthly Cost $ ___________________

Diagnosis and Stage of Disease _______________________________________________________________________________________________________________

Please list all medications and/or therapies that have been used to treat this condition, including strength of drug, frequency of dosing and duration of each treatment.

___________________________________________________________________________________________________________________________________________

What was the result of this treatment? _________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________

Expanded disability status scale (EDSS) score at time of diagnosis _________________________________________________________________________________

Provide the current Timed 25-Foot Walk Test (T25FW) speed ______________________________________________________________________________________

Renewal (3 and 6 months post initial approval):

Expanded disability status scale (EDSS) current score ____________________________________________________________________________________________

Provide the current Timed 25-Foot Walk Test (T25FW) speed ______________________________________________________________________________________

I hereby certify that the information provided in this request is true, complete and accurate.

Physician Signature _________________________________________________________________________________ Date _________________________________

MMM/DD/YYYY

PART 3 - PATIENT/GUARDIAN AUTHORIZATION

Co-operators Life Insurance Company Privacy Statement

Co-operators Life Insurance Company is committed to protecting the privacy, confidentiality, accuracy and security

of the personal information that it collects, uses, retains and discloses in the course of conducting business.

I authorize Co-operators Life Insurance Company (a) to use the personal information disclosed on this form, and any other personal information known to Co-operators Life

Insurance Company regarding the above-named patient, for the purpose of assessing this prior authorization request and any related claim and administering the benefit

plan under which any such claim is made, and (b) to contact, and to obtain any such personal information from and to disclose any such personal information to,

any physician, pharmacist or other health care professional having knowledge of such patient’s health relevant to this request and any related claim.

I hereby certify that the information provided in this request is true, complete and accurate.

Patient/Legal Guardian Name ________________________________________________________________ Telephone Number ( _______) _____________________

Signature of Patient/Legal Guardian _____________________________________________________________________

Date _______________________________

MMM/DD/YYYY

CO-OPERATORS LIFE INSURANCE COMPANY

GL2404 (06/14)

1920 COLLEGE AVENUE REGINA SK S4P 1C4

PG 1 of 1