Canada Life's diabetes step therapy program requires a plan member to have been reimbursed for a Step 1 drug before a Step 2 drug is covered. When a Step 1 drug is not an option, the prescriber uses this exception form to name the Step 2 drug requested, the Step 1 classes that cannot be tried and the contraindications, such as renal impairment with the latest creatinine clearance.
The plan member completes the plan member information and signs the consent; the prescribing physician completes the physician pages, including diagnosis, drugs, contraindications, signature and licence number.
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Diabetes Step Therapy Drug Exception Form
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It requires the plan member to have received reimbursement for a Step 1 antidiabetic drug before becoming eligible for a Step 2 drug. When a Step 1 drug is not an option, the prescriber can complete this exception form and submit it to Canada Life for consideration.
If a Step 1 drug was tried but coverage was not provided by Canada Life, the form asks for a pharmacy printout demonstrating the previous use. The note appears twice: in the plan member section and beside the physician's list of Step 1 drug classes.
The physician section asks whether the patient has type 2 diabetes and, if not, to give the indication, so another indication can be described. The prescriber then names the Step 2 drug requested and checks the Step 1 classes that cannot be tried, with the contraindication for each.