Canada Life plans may limit coverage of an originator biologic to that of its biosimilar, and this five-page request asks for originator coverage instead. The member reports treatment history, other coverage, disability benefits and patient support program enrolment; the physician records whether the patient is treatment-naive or already on the originator or a biosimilar, charts every biologic tried, and explains the rationale.
The plan member completes the plan member information page and signs the consent; the prescribing physician completes the physician section, including the treatment history chart, and signs with their licence number.
Download the current version from the source each time; forms change without notice.
Request for Originator Biologic 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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Canada Life's general information sheet says a benefits plan may limit coverage of an originator biologic to that of a biosimilar, which it describes as a highly similar version that is as effective and safe and typically less expensive. This form asks for an exception, with a detailed rationale for the originator.
A chart of all biologics tried, past and present, with dosing regimen, start and end dates, and the outcome of each (failure, intolerance or other) with clinical details. The physician also states whether the patient is treatment-naive, currently on the originator or currently on a biosimilar.
The member section asks whether the patient has enrolled in the drug's patient support program, with the program's patient ID and a contact. It also asks about drug coverage under any other benefits plan or provincial program, and whether the patient receives disability benefits for the condition.