While the majority of drugs listed on a formulary are processed immediately at the pharmacy counter, drugs that have been defined by our Medication Advisory Panel (MAP) as high cost specialty drugs require that specific criteria be met before reimbursement can be considered.
All of our criteria are developed under the guidance of the health care professionals on our MAP. Our prior authorization team, led by on-staff nurses and health care workers, translate these criteria into practice to support the right drug for the right patient at the right time, including ensuring prescribed drugs are being used for conditions approved by Health Canada.
Each case is managed uniquely, with prior authorization approvals granted for up to one year to allow for reassessment of the patient’s response to therapy. Our criteria may also include approvals with specific limits in alignment with product monograph. This allows reassessment of the patient’s response to therapy by our in-house teams. We are also able to define approval requests by applying specific limits on a member’s authorization record that can include; coinsurance, quantities and dollar maximums.
Members can use the Drug Search function on their Mobile App to confirm if a drug requires prior authorization. In most cases, high cost specialty drugs are aligned with a drug manufacturer sponsored Patient Support Program, and for certain drugs, enrolment in these programs are mandatory. Should a member require a high cost specialty drug, their specialist will directly engage them with these programs, or in the case of oncology a Cancer Care Navigator. Through our Patient First Network the member’s Case Worker and our in-house Special Authorization Unit work together on our member’s behalf to ensure required forms are completed, and a decision, many within 48 hours, is provided to get members to the right treatment in a timely manner.