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PRIOR AUTHORIZATION REQUEST

C. P. 3950Lévis (Québec) G6V 8C6Fax: 418-838-2134 1-877-838-2134

GROUP INSURANCE - HEALTH CLAIMS

Please read the instructions on the back of this form and complete the entire form. If any information is missing, the form will be returned to the member.

Desjardins Insurance life health retirement logo

Patient’s last name and first name Relationship with member Date of birth of patient

Member Spouse Dependent childMember’s last name and first name Contract no. Certificate no.

No., street, apt. City Province Postal code

Telephone nos: Home: Office: Extension:

By fax: ( ) - By mail (The response to your request will be sent to the address indicated in this section.)

YYYY MM DD

( ) - ( ) -

PROVINCIAL PLAN Yes - Please provide a copy of the notice of approval or refusal. Copy attached to this form.

No - Please explain: Yes NoIf so - Program name: - Contact person: Telephone no.: ( ) - Extension:

PATIENT SUPPORT PROGRAM

gHas a request for reimbursement been submitted under your provincial plan?

Is the patient enrolled in a patient support program?

Since the response to this request includes confidential information, please indicate how you would like to be informed of the decision:

A - PATIENT’S IDENTIFICATION TO BE COMPLETED BY THE MEMBER.

Information about your diagnosis should be provided by your attending physician; this section is therefore not accessible.

Drug name Formulation Strength Dosage Patient’s weight Scheduled duration of treatment

The patient is receiving or will receive the treatment in a hospital setting: Yes No

Diagnosis

Pediatric patient suffering from delayed growth due to growth hormone deficiency Growth hormone deficiency in a person whose bone growth has terminated (adult) Pediatric patient with Turner’s syndrome Pediatric patient with delayed growth related to chronic renal failure Pediatric patient with Idiopathic Short Stature Pediatric patient born small for gestational age Pediatric patient with Short stature Homeobox-containing gene (SHOX) deficiency HIV Other therapeutic indication(s) - Please specify:

Physician’s last name and first name (PLEASE PRINT) License no. Speciality

No., street, office City Province Postal code

Telephone no.: Fax no.:

Signature of physician: Date:

( ) - ( ) -

C - ATTENDING PHYSICIAN’S SECTION TO BE COMPLETED BY THE ATTENDING PHYSICIAN.

GENOTROPIN GOQUICK (SOMATROPIN)GENOTROPIN MINIQUICK (SOMATROPIN)

HUMATROPE (SOMATROPIN)NORDITROPIN NORDIFLEX (SOMATROPIN)

NUTROPIN (SOMATROPIN)OMNITROPE (SOMATROPIN)

SAIZEN (SOMATROPIN)SEROSTIM (SOMATROPIN)

Information relating to delayed growth due to growth hormone deficiency in pediatric patient

- Growth rate (percentile): - Serum or plasma somatropin - Please provide the date and results of two pharmacological stimulation tests:

Test 1: Test 2: Information relating to pediatric patient born small for gestational age

- Growth rate (in standard deviation score): - Weight or height at birth (in standard deviation score):

- Z score (The Z score represents height compared to the average of normal values for age and sex):

All the information I have provided on the claim form is accurate and complete. I authorize Desjardins Financial Security Life Assurance Company, hereinafter Desjardins Insurance, strictly for the purposes of managing my file and settling this claim to: (a) collect from any person or legal entity, or from any public or parapublic organization, only the information deemed necessary to manage my file. The non-exhaustive list of sources from which information may be collected includes health care professionals or facilities, insurance companies; (b) communicate to the said persons or organizations only the personal information about me that is deemed necessary for the purposes of my file; (c) when necessary use the personal information it may have about me in existing files that are now closed. This authorization is also valid for the collection, use and communication of personal information concerning my dependents, insofar as applicable to the claim. A photocopy of this authorization is as valid as the original.

Signature of member Date

Last name and first name of parent/legal guardian (if necessary)

Signature of patient or parent/legal guardian (if necessary): Date:

B - DECLARATION AND AUTHORIZATION FOR THE COLLECTION AND COMMUNICATION OF PERSONAL INFORMATION

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C - ATTENDING PHYSICIAN’S SECTION (CONTINUED)

Prior medication or treatment Has the patient ever used medication or received treatment for this condition? Yes No

If not, please explain: If so, please list the medication or treatment already used for this disease:

Prescription renewalPlease provide objective evidence of efficacy:

YYYY MM DD YYYY MM DD

Medication or treatment Dose Start date End date Outcome name (provide details of intolerance, contraindication or failure)

The drug may be eligible for reimbursement only if it meets the insurer’s criteria, if it is not administered in a hospital setting and if it is not covered under a provincial drug insurance plan or a government program.If you are enrolled in a provincial drug insurance plan, please submit your claim to this plan first since it may cover this drug. If your claim is refused by your provincial drug insurance plan, please send us a copy of the notice of refusal and the form completed by your physician so that we can analyze your file.

- by mail: Desjardins Insurance Group Insurance, Health Claims C. P. 3950, Lévis (Québec) G6V 8C6

- by fax: Desjardins Insurance Group Insurance, Health Claims, 418-838-2134 or 1-877-838-2134 (toll free)

Information relating to growth hormone deficiency in a person whose bone growth has terminated

- Serum or plasma somatropin:

- Is the deficiency secondary to: delayed growth during childhood a pituitary disease a hypothalamic disease a surgery radiotherapy a trauma

Information relating to Turner’s syndrome in pediatric patient

- The syndrome has been demonstrated by: Complete absence of one of the X chromosomes Structural anomaly of one of the X chromosomes

Information relating to delayed growth related to chronic renal failure in pediatric patient

- Glomerular filtration rate: ml/min/1.73m2

- Height (percentile): - Z score (The Z score represents height compared to the average of normal values for age and sex):

Information relating to idiopathic short stature in pediatric patient

- Weight at birth: - Z score (The Z score represents height compared to the average of normal values for age and sex):

- Growth rate (percentile): - The patient is unlikely to attain adult height in the expected range: Yes No

- Are the patient’s epiphyses closed? Yes No

Information relating to Short stature Homeobox-containing gene (SHOX) deficiency in pediatric patient

- Are the patient’s epiphyses closed? Yes No

Under its prior authorization program, Desjardins Insurance approves the payment of certain claims that meet criteria established jointly with healthcare consultants. If the information on your form is complete, your request will normally be processed within 5 business days. When the request form is received, it will be assessed in the strictest confidence. In some situations, additional diagnostic or clinical information may be required.If the treatment continues beyond the authorized period, you will be asked to submit a new request form and provide information that justifies the extension of treatment. If you have an Express Scripts Canada card, your pharmacist will be advised that the authorization period is coming to an end.The insurance must be in force and the patient still covered at the date expenses are incurred. This prior authorization is subject to change if, at the time expenses are incurred, the contract has been modified.When a prior authorization is rejected, it means that Desjardins Insurance refuses to pay for a product. It is not an indication that Desjardins Insurance is challenging the opinion of the physician. If you have any questions, please contact our Customer Contact Centre.

or by mail to Desjardins Insurance, Group Insurance, Health Claims Postal code 3 9 5 0, Lévis Québec G 6 V 8 C 6

by fax to Desjardins Insurance Group Insurance Health Claims 4 1 8 8 3 8 2 1 3 4 or toll free 1 8 7 7 8 3 8 2 1 3 4

1. Complete sections A and B. 2. Ask your physician to complete section C. The member is responsible for assuming any costs incurred to complete this form or to obtain additional information. 3. To obtain a reimbursement once the drug has been approved, please use your Express Scripts Canada card at the pharmacy or submit your original receipts by mail.

Eligible drugs must be dispensed by a pharmacist or a physician, if there is no pharmacist.4. Send form:

INSTRUCTIONS - HOW TO COMPLETE AND RETURN THIS FORM