IMPORTANT NOTICE: As of Jan. 1, 2020, The Great-West Life Assurance Company, London Life Insurance Company and The Canada Life Assurance Company became one company – The Canada Life Assurance Company. It will take some time to update our websites, materials and forms, so until we’re done, all references to Great-West Life or London Life are to be understood as referring to The Canada Life Assurance Company. Learn more

Brand name coverage form

Print and complete the request for brand name drug coverage form.

Request for Brand Name Drug Coverage Form

Certain prescription drug claims need to be approved before we can consider reimbursement.

If your group benefits plan limits the reimbursement for brand name drugs to the cost of the generic drug but you have a legitimate medical reason for requiring the brand, you may request coverage for the brand name drug by submitting a completed Request for Brand Name Drug Coverage form.

Select the Request for Brand Name Drug Coverage form.
Print the form.
Ask your attending physician to complete it.
Send the completed form to us by mail or fax.

Request for Brand Name Drug Coverage form M7088 - 123 kb
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