Erectile dysfunction therapy: viagra (sildenafil), cialis (tadalafil), levitra (vardenafil), and staxyn (vardenafil) - prior authorization form - assure claims
PRIOR AUTHORIZATION PROGRAM REIMBURSEMENT REQUEST FORM Please fax form to:
For erectile dysfunction therapy: Viagra (sildenafil), Cialis (ta
dalafil), Levitra (vardenafil) and Staxyn (vardenafil
Please note that the patient AND
physician must complete this form. Incomplete forms may result in a delay in your request being
Please retain a copy of this form for your records. Instructions:
1. PLEASE PRINT CLEARLY AND COMPLETE ALL SECTIONS.
The patient/plan member must complete section A.
Your physician must complete section B. The cost, if any, of completing this form is at the expense of the patient/plan member.
Please return the form to your insurance company via Pharmacy Services at TELUS Health (a service provider of your insurance company) by fax to
mail to TELUS Health, 4141 Dixie Rd. P.O. Box 41154, Mississauga, Ont. L4W 5C9.
If you have any questions on the application of this program or the decision on reimbursement, or to inquire on the status of your Reimbursement
Request Form, please contact your insurer.
A. Information to be Completed by Patient
Employee or Insured’s Name
__ __ - __ __ __ __ __ __ - __ __ __ __ __ __ __ __ __ __ - __ __
Relationship to Employee/Insured (please circle)
Please allow two business days for a response once all information is received and complete. Notification of the
results of this request will occur Monday to Friday between 9 am and 4 pm Eastern Time.
Please provide contact information and indicate ONE method of preferred contact for notification of the results:
e-mail me at: _____________________________________
call me (and leave a message if I’m not there) at: (_____)________________
fax me at:( ___)__________________________________
contact my pharmacy at pharmacy name:____________________________ phone no.: (_____)__________________ I certify that the information provided by me is true, correct and complete to the best of my knowledge. I authorize my insurance company,
TELUS Health a service provider of my insurance company), their authorized representatives, agents and service providers to use and exchange this
information needed for underwriting, administration and paying claims with any person or organization who has relevant information pertaining to
this claim including health professionals, institutions and investigative agencies in the event of an audit. I authorize my insurance company and/or
TELUS Health (a service provider of my insurance company) to contact any licensed physician, institution, pharmacy or person who has any records or
knowledge of me or my health with respect to this submitted claim.
SIGNATURE OF PATIENT/PARENT/LEGAL GUARDIAN ______________________________________________________ Date (D/M/Y): _______________
B. Information to be Completed by Prescribing Physician
Drug Name:_______________________________________ Strength:____________________ Dose:___________________________________________
Coverage of Viagra (sildenafil), Cialis (tadalafil), Levitra (vardenafil), or Staxyn (vardenafil) is NOT
provided for female patients,
males < 18 years, patients receiving nitrate therapy or patients with psychogenic or primary erectile dysfunction. Viagra (sildenafil),
Cialis (tadalafil), Levitra (vardenafil), or Staxyn (vardenafil) will be eligible for reimbursement only if the patient satisfies one of the
criteria listed below and if the patient does not qualify for coverage under any other drug plan or government mandated program. If
the patient is covered under another drug plan or government mandated program, the prior authorization program, as part of your
drug benefits, may cover the portion not paid for by the primary plan. However, if “none of the above criteria” is indicated, the
patient will not be eligible for reimbursement. For Quebec plan members, please refer to the RAMQ exception drug criteria, if
Please indicate if the patient satisfies one of the following criteria:
Organic erectile dysfunction (e.g., diabetes related, vascular related). Erectile dysfunction with a neurologic cause (e.g., spinal cord injury, nerve damage as a result of a prostatectomy or TURP). Drug induced erectile dysfunction where it would be inappropriate to alter or discontinue the drug contributing to the erectile
Mixed Psychogenic/Organic erectile dysfunction.
None of the above criteria applies.
The most current version of this form supersedes all prior versions. The form may be modified without notice to you and we reserve the right to accept only the current version. Revised January 2014. EDE_1401
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