4233-pa-ed-e (g2718-e)

Prior Authorization FormFor erectile dysfunction therapy: ViagraTM (sildenafil), Cialis® (tadalafil),LevitraTM (vardenafil) Sun Life Assurance Company of Canada, a member of the Sun Life Financial group of companies, is committedto keeping your information confidential.
Please print clearly and be sure all sections are complete to avoid delays in processing. Retain a copy of this form for your records.
1. Please complete Section A.
2. Please have your physician complete Section B. You are responsible for any cost required by your physician to complete this form.
3. Please fax the form to Emergis Inc. at 1 866-840-1509, or mail to Emergis Inc. 4141 Dixie Rd PO Box 41154 Mississauga ON L4W 5C9.
4. If you have any questions, please call 1 800-361-6212.
A | Information to be completed by patient
We will get back to you with
our decision within 2 business
_ _ - _ _ _ _ _ _ - _ _ _ _ _ _ _ _ _ _ - _ _ days from the date we receive
all the information necessary

Relationship to plan member ( please circle) to make a decision.
Notifications occur Monday to
Friday, between 9am and 4pm

Contact Information: Given the confidential nature of your information, please specify how you want to be
Eastern Standard Time.
notified of our decision on your request for coverage.
२ contact my pharmacy: Pharmacy name: ______________________________ Phone No. ________________________ २ call me (and leave a message if I’m not there) at: ________________________ २ e-mail me at: ________________________________________________________२ fax me at: ________________________ I certify that the information provided above by me is true and complete. I authorize Sun Life Assurance Company ofCanada, its agents and service providers to use and exchange information needed for underwriting, administration andadjudicating claims under this Plan with any person or organization who has relevant information pertaining to thisclaim including health professionals, institutions, investigative agencies, insurers and reinsurers. I understand thatinformation about me pertaining to this claim may be reviewed in the event that this Plan is audited. I agree that aphotocopy or electronic version of this authorization shall be as valid as the original.
Signature of patient/parent/legal guardian B | Information to be completed by prescribing physician
Coverage of Viagra™ (sildenafil), Cialis® (tadalafil) or Levitra™ (vardenafil) is NOT provided for female patients, males < 18 years, patients
receiving nitrate therapy or patients with psychogenic or primary erectile dysfunction. Viagra™ (sildenafil), Cialis® (tadalafil) or Levitra™
(vardenafil) may be eligible for reimbursement for male patients if one or more of the following criteria is satisfied. If “none of the above
criteria” is indicated, the patient will not be eligible for reimbursement.
Please indicate if the patient satisfies one of the following criteria: २ Organic erectile dysfunction (e.g. diabetes related, vascular related)२ Erectile dysfunction with a neurologic cause (e.g. spinal cord injury, nerve damage as a result of a prostatectomy or TURP)२ Drug induced erectile dysfunction where it would be inappropriate to alter or discontinue the drug contributing to the erectile dysfunction२ Mixed Psychogenic/Organic erectile dysfunctionOR२ None of the above criteria applies.

Source: http://www.nortel-canada.com/benefits/PriorAuthorizationForm_ErectileDysfunctionTherapy.pdf

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