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GROUP BENEFITS

PRIOR AUTHORIZATION FORM

BOTOX

(OnabotulinumtoxinA) - CHRONIC MIGRAINE

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 _________________________

Starting Dosage _____________________

Type of Migraine ______________________________________________________________________________________________________________________________

Is Botox being prescribed for the prophylaxis of migraines in adult patients with chronic migraine in which acute (triptans) and prophylactic migraine medications have

failed or are inappropriate?

Yes

How many migraines (on average) has the patient experienced per month over the last 3 months? ______________

What has been the highest monthly count during that period? ______________

What has been the lowest monthly count? ______________

Duration of typical migraine ______________

NOTE: The administration of Botox for cosmetic purposes is strictly excluded from coverage.

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

GL2329 (05/15)

1920 COLLEGE AVENUE REGINA SK S4P 1C4

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