Form Gl2423 - Group Benefits Prior Authorization - Effient (Prasugrel)

GROUP BENEFITS

PRIOR AUTHORIZATION FORM

EFFIENT (prasugrel)

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 _________________________________________________________________________________________________________________

Does the patient have Acute Coronary Syndrome (ACS) which was diagnosed within one year of unstable angina (UA), non-ST elevation

myocardial infarction (NSTEMI), or ST elevation myocardial infarction (STEMI) treated with percutaneous coronary intervention (PCI)?

..................

Yes

Has the patient had angiographically demonstrated definite stent thrombosis while on clopidogrel?

.....................................................................

Yes

If yes, is the thrombosis at the stent site?

.....................................................................................................................................................

Yes

Does the patient have true, documented clopidogrel allergy?

...............................................................................................................................

Yes

If yes, provide details regarding date of the allergic event, type and description of event __________________________________________

_____________________________________________________________________________________________________________________

Has the patient had an intolerance to clopidogrel?

...............................................................................................................................................

Yes

Has the patient had a stroke or transient ischemic attach (TIA)?

...........................................................................................................................

Yes

Is the patient 75 years or older?

..........................................................................................................................................................................

Yes

Is the patient’s body weight less than 60 kg?

.......................................................................................................................................................

Yes

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

GL2423 (11/14)

1920 COLLEGE AVENUE REGINA SK S4P 1C4

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