Form Gl2419 - Group Benefits Prior Authorization - Abstral

GROUP BENEFITS

PRIOR AUTHORIZATION FORM

ABSTRAL (fentanyl)

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 _________________________________________________________________________________________________________________

Is the patient 18 years old or older?

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

Yes

Does the patient have breakthrough cancer pain?

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

Yes

Is the patient already receiving opioid therapy for persistentcancer pain, using one of the following?

At least 60 mg oral morphine/day

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

Yes

At least 25 mcg transdermal fentanyl/hour

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

Yes

At least 30 mg oral oxycodone

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

Yes

At least 8 mg oral hydromorphone daily

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

Yes

An equianalgesic dose of the opioid for a week or longer

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

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

GL2419 (11/14)

1920 COLLEGE AVENUE REGINA SK S4P 1C4

PG 1 of 1