Canada Life workplace plans may limit a drug's covered cost to a lower-cost alternative, and this request asks for coverage of the brand-name drug instead. To qualify, medical evidence must show the patient has adverse side effects from the generic version. The prescriber identifies both drugs by DIN and describes the reaction, its outcome and its severity; approval may be time-limited.
The plan member completes the plan member information and the policyholder signs the consent; the prescribing physician completes the physician section, including both DINs, the reaction details and a signature.
Download the current version from the source each time; forms change without notice.
Request for Brand Name Drug Coverage
Upload the fillable PDF once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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When medical evidence shows the patient experiences adverse side effects from the generic version. The prescriber records the outcome of the reaction (life threatening, hospitalization, allergic reaction or other) and describes its nature, extent and severity, along with the anticipated duration of therapy.
The name, DIN and dosage or frequency of the brand-name drug requested, and the same details for the generic drug that was prescribed. The prescriber also gives specialty, address, phone and fax, then signs and dates the form.
Not necessarily. Canada Life states that if a request is approved, coverage may be granted for a set period of time, after which the member needs to re-apply for continued coverage. Assessment may also be delayed if the form is incomplete.