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Desjardins General Prior Authorization Form (10108E)

Desjardins Insurance group plans use this three-page general form for prior authorization of a drug that has no drug-specific form. The attending physician documents the drug, dose, weight, site of administration, diagnosis, the condition's effects, prior treatments and their outcomes, and, for renewals, objective evidence of response. Desjardins assesses it against criteria based on clinical practice guidelines and health technology assessments.

Who completes it

The plan member completes section A and signs section B1, with optional consent in B2 to share the decision; the attending physician completes and signs section C.

Submitting and payment

How to submit it
Submit online through the plan member secure site (select Prior Authorization Request, Drugs), or by fax or mail; complete requests are normally processed within 5 business days.
Who pays
The plan member is responsible for any costs of completing the form or obtaining additional information.

Good to know

  • A drug qualifies only if it meets Desjardins' criteria, is not administered in hospital and is not eligible under a government program.
  • Incomplete forms are returned to the plan member; attach lab, test or imaging results and supporting guidelines or studies, but no genetic test results.
  • If the patient has private or provincial drug coverage, submit there first and send Desjardins the decision notice with this form.
  • Treatment beyond the authorized period needs a new request with justification; with a payment card, the pharmacist is told when the authorization is ending.

Get the official form

Download the current version from the source each time; forms change without notice.

Prior authorization request – General form

Demande d'autorisation générale pour un médicament

Official pagePDFVersion française

Fill it with Vero

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms change without notice, so download the current version from the official page before you fill it in.

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Frequently asked questions

When should I use the Desjardins general prior authorization form?

When the drug requiring prior authorization does not have its own form on Desjardins' alphabetical list. The general form, 10108E (French 10108F), collects the core information: the drug and dosage, diagnosis, the condition's effect on the patient, and prior treatments with their outcomes.

What does the physician need to attach to form 10108E?

Clinical examination results such as laboratory tests or imaging reports, and documents that justify the drug's use in the context, such as clinical practice guidelines or studies. The form says not to disclose any genetic test results, and missing sections send the request back to the plan member.

Does a Desjardins refusal mean it disagrees with the physician?

No. The form states that when Desjardins declines a prior authorization request, it is upholding conditions set out in the insurance contract and is not questioning the physician's opinion. Questions can go to Desjardins' Client Relations Centre at the number on page 1.