Pharmacy Providers

• Acquisition Cost Request Pharmacy providers only should use this form to request "cost-to-operator " adjustments in the event that reimbursement on a given claim was less than your actual acquisition cost for the item claimed.
• Adjustment Pharmacy providers only should use this form to correct any incorrect or unknown information on the initially submitted claim (eg. to correct an incorrect DIN, correct a package size, quantity, or days supply,etc.).
• Claim Reversal Request
• Drug Authorization Forms A Drug Special Authorization form is required when a pharmacy receives a denial for an electronic drug claim that requires prior authorization.
• Fill Limits Exception Request Form Request for coverage of additional dispensing fees associated with exceptions to the maintenance medication dispensing frequency policy (3 months supply) and/or use of compliance packaging.
• Pharmacy Claim Submission Form Pharmacy providers may use this form to submit a manual claim in the event that the claim cannot be processed electronically. This form can be used for regular or compound claims.
• Request for Approval of Brand Name Drug

GreenShield Insurance's Update newsletters give you the latest information on trends in the industry and GreenShield Insurance news. Please choose from the list below (available in PDF format):

Select a document below to view (in PDF) or print a copy:

For more detailed inquiries about drug eligibility, criteria, other GreenShield Insurance policies, etc., please contact our Customer Service Centre at 1-888-711-1119.

• Drug Authorization Forms A Drug Special Authorization form is required when a pharmacy receives a denial for an electronic drug claim that requires prior authorization.

• Claim Reversal Request
• Drug Authorization Forms A Drug Special Authorization form is required when a pharmacy receives a denial for an electronic drug claim that requires prior authorization.

Select a document below to view (in PDF) or print a copy:

For more detailed inquiries about drug eligibility, criteria, other CCQ policies, etc., please contact our Customer Service Centre.

• Drug Authorization Forms A Drug Special Authorization form is required when a pharmacy receives a denial for an electronic drug claim that requires prior authorization.

• Acquisition Cost Request Form Pharmacy providers only should use this form to request "cost-to-operator " adjustments in the event that reimbursement on a given claim was less than your actual acquisition cost for the item claimed.
• Claim Reversal Request
• Pharmacy Adjustment Form Pharmacy providers only should use this form to correct any incorrect or unknown information on the initially submitted claim (eg. to correct an incorrect DIN, correct a package size, quantity, or days supply,etc.).
• Pharmacy Claim Submission Form Pharmacy providers may use this form to submit a manual claim in the event that the claim cannot be processed electronically. This form can be used for regular or compound claims.

SSQ Insurance’s Update newsletters give you the latest information on trends in the industry and SSQ Insurance news. Please choose from the list below (available in PDF format):

Select a document below to view (in PDF) or print a copy:

For more detailed inquiries about drug eligibility, criteria, other SSQ Insurance policies, etc., please contact our Customer Service Centre at 1(800) 463-6262