Desjardins group plans cover a brand-name drug only up to the price of the lowest-cost generic equivalent, and this two-page request asks for an exception. It is approved only if the attending physician gives an acceptable medical reason the patient cannot take that generic: a documented allergy or severe intolerance, including the non-medicinal ingredient that caused it. Desjardins' physician or pharmacist may review it.
The plan member completes sections A and B, with a separate signature from any insured dependent aged 16 or over; the attending physician completes section C, the physician's statement, and section D, identification and signature.
Download the current version from the source each time; forms change without notice.
Request for reimbursement of brand-name medications
Demande de remboursement pour un médicament de marque
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Only if this exception is approved. Otherwise the brand-name drug is covered up to the price of the lowest-cost generic equivalent on the market. Approval requires the attending physician to give an acceptable medical reason, specifically an allergy or severe intolerance, why the patient cannot take that generic.
The generic drug that caused the reaction, whether it was an allergy or intolerance, the outcome, a full description with the interventions used to treat it, the onset date, the non-medicinal ingredient responsible, and whether that ingredient is in the brand-name drug or absent from other generics available in Canada.
Online through the plan member's secure site, by choosing Send documents under Tools and resources and selecting this form, or by fax or mail. The member should keep a copy, and the request is assessed on the medical information the physician provides.