For erectile dysfunction therapy: Cialis (tadalafil), Levitra (vardenafil),
Sun Life Assurance Company of Canada, a member of the Sun Life Financial group of companies, is committed to keeping your information confidential.
1 | Important – please read carefully
Please note that the completion of this form is not a guarantee of approval. It must be completed in full otherwise it will be returned to you. Any expense for medical evidence to support this request is your responsibility. Given the confidential nature of your information, we will issue our response to you in writing. If you have already purchased the medication for which you are requesting prior authorization, please attach all original receipts along with a regular extended health care claim form. 2 | To be completed by plan member Plan member information Claimant information Authorization and signature I certify that the information I provided above is true and complete. I authorize Sun Life Assurance Company of Canada, its agents and service providers to collect, use and disclose information needed for underwriting, administration and adjudicating claims under this Plan with any person or organization who has relevant information pertaining to this application including health professionals, institutions, investigative agencies, insurers and reinsurers. I agree that a photocopy or electronic version of this authorization shall be as valid as the original.
Page 1 of 3 4233-PA-ED-E-11-12 (G2718-E) 3 | To be completed by prescribing physician
Prescribing physician’s last name (please print)
Coverage of Cialis (tadalafil), Levitra (vardenafil), Staxyn (vardenafil) or Viagra (sildenafil) is NOT provided for female patients, males < 18 years, patients receiving nitrate therapy or patients with psychogenic or primary erectile dysfunction. Cialis (tadalafil), Levitra (vardenafil), Staxyn (vardenafil) or Viagra (sildenafil) will be eligible for reimbursement only if the patient satisfies one of the criteria listed below. If the patient does not satisfy any of the criteria, then the drug will not be eligible for reimbursement (please confirm by checking off the last box below). The eligible expense under this plan is that portion of the expense that is not payable or available under a government-sponsored drug program or another drug plan.
If approved, approval for coverage of this drug may be reassessed at any time at Sun Life Assurance Company of Canada’s discretion.
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
Drug induced erectile dysfunction where it would be inappropriate to alter or discontinue the drug
contributing to the erectile dysfunction.
Mixed psychogenic/organic erectile dysfunction.
None of the above criteria applies. Relevant additional information
Respecting your privacy
Page 2 of 3 4233-PA-ED-E-11-12 (G2718-E) Mailing instructions – keep a copy for your records Mail or fax your completed Sun Life Assurance Company Sun Life Assurance Company of Canada of Canada Fax number: 1-855-342-9915
Page 3 of 3 4233-PA-ED-E-11-12 (G2718-E)
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