SPECIAL AUTHORIZATION REQUEST
SEE BACK OF FORM FOR PROCEDURES
THIS FORM PREVIOUSLY FAXED (DATE):
Please complete entire
form. If information is missing from the form it will be returned to the member. Incomplete forms cannot be processed. Any costs
associated with the completion of this form or obtaining additional medical information are the responsibility of the patient/member.
PATIENT INFORMATION (To be completed by the Member/Patient. )
* Have you already purchased your prescription requested by your physician below?
If you have already submitted your receipt to Medavie Blue Cross, please indicate the date of the oldest receipt. Date (dd/mm/yyyy):
Please attach your paid-in-full receipt with this request form.
Do you or any dependents have other coverage under any other plan? Yes No If Yes, complete the following:
I hereby authorize any health care provider to release to Medavie Blue Cross, any medical information about myself and my dependents which relates to claims submitted by us, or on our
behalf, to Medavie Blue Cross.
I understand that the personal information provided herein, as well as any other personal information currently held or collected in the future by Medavie Blue Cross and/or Blue Cross Life InsuranceCompany of Canada, may be collected, used, or disclosed to administer the terms of my policy or the group policy of which I am an eligible member, to recommend suitable products and services tome, and to manage Blue Cross’s business. Depending on the type of coverage I carry, limited personal information may be collected from and/or released to a third party. These third parties includeother Blue Cross organizations, health care professionals or institutions, life and health insurers, government and regulatory authorities, the member of any policy under which I am a participant andother third parties when required to administer and manage the benefits outlined in the policy of which I am an eligible member.
I understand that my personal information will be kept confidential and secure. I understand that I may revoke my consent at any time; however, in some instances doing so may prevent Blue Cross fromproviding me with the requested coverage or benefits. I understand why my personal information is needed and I am aware of the risks and benefits of consenting or refusing to consent to its disclosure.
I authorize Medavie Blue Cross to collect, use and disclose my personal information as described above.
(If under 18 years of age the signature of the member is required.)
A photocopy of this authorization shall be as valid as the original. This consent complies with federal and provincial privacy laws. For additional information on privacy policies at Medavie Blue Cross,visit www.medavie.bluecross.ca or call 1-800-667-4511.
DRUG REQUESTED FOR SPECIAL AUTHORIZATION
For injectables, facility where medication is administered
If the product requested is in one of the categories below, please complete the applicable section in addition to the above.
Beclomethasone and budesonide are regular benefits. Have they beentried?
Yes If not, is there any medical reason why they
ALZHEIMER'S DISEASE TREATMENT
FAMVIR, VALTREX, ZOVIRAX
Has there been a consultation with a neurologist?
Please specify if treating oral herpes, genital herpes, or herpes zoster
BIOLOGICAL RESPONSE MODIFIERS
If for oral herpes, and not immunocompromised, please describe extent of
PROTON PUMP INHIBITORS
DMARDS doesn’t apply to psoriasis and ankylosing spondylitis
Pariet, Tecta and generic Omeprazole are regular benefits. Have 2 out ofthe 3 medications been tried?
Applies only to psoriasis
If not, is there any medical reason why they cannot be tried?
Have systemic therapy and photochemical therapy been tried?
LONG-ACTING BRONCHODILATORS AND LEUKOTRIENE
Is the patient presently using optimum inhaled steriods and still requiring
short-acting bronchodilators more than three times weekly?
Are there any existing comorbid conditions? (please specify)
TM The Blue Cross symbol and name are registered trademarks of the Canadian Association of Blue Cross Plans, used under licence by Medavie Blue Cross, an independent licensee of the Canadian Association of Blue Cross Plans.
PROCEDURES FOR SPECIAL AUTHORIZATION
Special Authorization is a pre-approval process to determine if certain productswill be reimbursed under your benefit plan.
Eligible prescriptions must be purchased at a Medavie Blue Cross approvedprovider.
Special authorization coverage is contingent on your continued status as aMedavie Blue Cross cardholder or beneficiary.
If your plan is based on reimbursement, submit your original paid-in-full receipt toMedavie Blue Cross to be considered for reimbursement.
This form must be completed by your attending physician and forwarded to:
Private and Confidential
Medavie Blue Cross
Special Authorization - Prescription Drugs
PO Box 220
Moncton NB E1C 8L3
or fax (506) 867-4580 (Confidential Line)
Upon receipt, this request will be confidentially reviewed according to payment criteriadeveloped by Medavie Blue Cross in consultation with independent health careconsultants. In some cases, additional diagnostic or clinical information may berequired. Medavie Blue Cross will send you a written response.
Special Authorization may be limited to a specified time period and/or quantity ofmedication. Renewal of the Special Authorization will be considered by Medavie BlueCross upon request from the patient/member. The renewal request shouldinclude information from the physician supporting continued use of the medication.
If the information on your form is complete, the usual turnaround time for assessment isseven to 10 working days. In cases where you require an urgent response due to amedical condition, every effort will be made to respond the same day. If you wish tohave a response faxed back to you, request this in writing on your Special Authorizationform. If you wish to know the status of your Special Authorization request, please callour Customer Service Centre at 1-800-667-4511.
NOTE TO PHYSICIAN
Under the Special Authorization program, Medavie Blue Cross grants approvalfor payment of certain benefits if they fall within certain established criteria. Bydenying a request for Special Authorization, Medavie Blue Cross is denyingpayment for a product and is not challenging the medical opinion of the physiciannor rendering a medical opinion.
ASCO 2013 Title and body: 2000characters (300 – 350 words) Co-authors: up to 20 people Topic categories: 1) triple-negative breast cancer, 2) cytotoxic chemotherapy ********************** Phase II study of neoadjuvant chemotherapy including a metronomic regimen of paclitaxel + cyclophosphamide + capecitabine followed by 5-fluorouracil + epirubicin + cyclophosphamide
Note: The following is not medical advice. The author is a biochemist, not a physician, and the sole intent of this fact sheet is EDUCATION. It is not meant to take the place of medical advice, nor should anyone reading this material stop taking drugs prescribed by their physician. In fact, the best use of this material is in discussion with your physician , as part of a health partnership desi