WebSubmit the Prescription Drug Special Authorization Form to GSC: g By email: Scan the document and email to [email protected] g By mail: Green Shield Canada, Attn: Drug Special Authorization, P.O. Box 1606, Windsor, ON N9A 6W1 g By fax: 1.866.797.6483. 3 greenshield.ca PM-PRIORAUTH-001-E WebOnce completed, this form can be returned to Great-West Life at the address, fax # or email shown below. Mail to: The Great-West Life Assurance Company Fax to: Drug Services PO Box 6000 The Great-West Life Assurance Company Winnipeg MB R3C 3A5 Fax 1.204.946.7664 Canada Attention: Drug Services Email to: [email protected]
Drug Prior Authorization Form - Canada Life
WebMar 13, 2024 · Coverage of special authorization drugs will be assessed: according to defined criteria; upon receipt of the required clinical information from a health care provider involved in the patient’s care; and subject to a drug review by staff of the Pharmaceutical Services Division. WebThe completed Request for Special Authorization form can be returned to Great-West Life by mail or fax. Mail to: The Great-West Life Assurance Company Fax to: The Great-West Life Assurance Company Drug Services Fax 1-204-946-7664 PO Box 6000 Attention: Drug Services Winnipeg MB R3C 3A5 Part 3 Physician Information (continued) chrome messenger bags machine wash
Form Completion Instructions - Government of …
WebAuthorization drugs which are indicated in bold italics. The Prior Authorization forms can be found at ca n adapost.ca/druqplan o r call Great -West Life at 1-866-716-1313. PLAN MEMBER INFORMATION Please select your plan number: o 51391 or o 162954 (MGT/XMT who retired on or after January 2, 2011) Employee/Retiree ID Name : Address: WebNote for Physician: To be eligible for reimbursement, Great-West Life may require your patient to purchase a drug requiring prior authorization from a pharmacy designated by Great-West Life. If applicable, a health case manager will contact you with further … WebDrug Prior Authorization Form Rituxan (rituximab) The purpose of this form is to obtain information required to assess your drug claim. ... Mail to: The Canada Life Assurance Company Drug Claims Management PO Box 6000 Winnipeg MB R3C 3A5 Fax to: The Canada Life Assurance Company Fax 1-204-946-7664 chrome mesh wheels