The Prior Authorization Claims Process and You

Earlier we explained how and why a prescription drug becomes a specialty drug, and why specialty drugs are subject to a process called prior authorization, sometimes also called special authorization. Prior authorization is a series of administrative steps in the claims process that are decided by your group benefits insurer. These steps must be followed before reimbursement for a claim will be considered. Once all the information is submitted, you will be advised whether your claim is approved, usually by mail or by phone with a follow up notice by mail. In this section, we will give you more information on the prior authorization claims process. There are professionals who can help you through the process. You may also want to review the list of prior authorization stakeholders that may be able to help you prepare and submit your specialty drug claim.

Physicians

The prior authorization claims process begins when you are prescribed a drug to treat a medical condition. The healthcare practitioner who prescribes your drug, usually your physician, may or may not know that the drug they are prescribing will require prior approval from your insurer. If it is a drug(s) they have prescribed to other patients, they should have a good idea whether the drug(s) will be covered by one of the following:

A public drug program in your province
Your group benefits provider
Or whether you will need to apply to a compassionate program offered directly by the pharmaceutical manufacturer.

If the drug you are prescribed is not covered by any provincial drug plan then you should submit a claim to your group insurer through the prior authorization process. You will also need to provide written information for your claim including:

The name of your insurer
Policy, and certificate number
Your signature

If you are not sure where to locate your policy and certificate number, your human resources department can help. You can check out our tips in Do You Have Prescription Drug Coverage.

The staff at your prescribing physician’s office should be able to give you some guidance on how the claims process will work for the drug you are prescribed, including the forms that will need to be completed.

Help from your physician’s office – If your physician is familiar with the prior authorization process, they will probably have access to the claim form you require, or at least know how to find it. They may also have staff to help complete the claim form and attach the necessary medication documentation, or they may refer you to a Patient Support Program (PSP).
Help from outside your physician’s office – If your physician is not familiar with the prior authorization process for the drug(s) they have prescribed, they can use the physician section of this website for more information on prior authorization or they can use the Resources page on this site to access links to each insurer. Insurers can advise your physician about what claim forms are necessary. They may also refer you to one of the organizations in the Resources page for assistance in completing forms and submitting your drug(s) claim.

Even with some guidance from your physician, the prior authorization claims process for specialty drugs can be difficult to navigate. You will probably need some help from an expert in the process who will work with you during the claims process to achieve a timely and fair reimbursement decision.
You can also ask for help from one of the following experts:

A patient support program (PSP)
A drug access navigator (DAN)
A specialty pharmacy
Your local pharmacy

Patient support program (PSP)

Patient Support Programs (PSPs) are services delivered by dedicated PSP companies and funded by pharmaceutical companies. The programs are designed to provide features and support for patients who are prescribed certain specialty medications. PSPs help patients navigate the complexities of both the public and private reimbursement process.

Patient support programs may also have funds available to them through a patient assistance program to help with the cost of your medication. If you do not have coverage elsewhere or if your drug is not completely covered either through a provincial drug plan or your group benefits plans, then a PSP may be able to help.

Your prescribing physician should be able to direct you to the PSP for the drug they have prescribed.

If it is unclear whether there is a PSP for the drug you have been prescribed, you can:

Contact the pharmaceutical manufacturer’s general information/medical information phone number
Look online through the product name you have been prescribed or on the manufacturer’s Canadian website
Look online at the patient organization for your condition. Some patient organizations are listed on the Resources page of this website.

You can find out more tips on this under the Resources page of this website.

Drug access navigator (DAN) - in the case of cancer therapies

Your physician may also refer you to a drug access navigator (DAN), who are publicly funded, and primarily work with cancer patients. Your DAN will be able to help you with enrollment if a patient support program (PSP) exists.

Also known as drug access facilitator or medication reimbursement specialist, DANs work to connect a patient with the medication or treatment they require.

Currently, DANs are mostly found in cancer clinics but are increasingly available to help patients with other conditions, like Multiple Sclerosis and Cystic Fibrosis. If you are being treated at a cancer centre, ask your physician if there is a DAN or someone in a similar role that can help you through the claims process. A pharmacist or social worker may do the role of the DAN even by a different title. You can find out more about DANs through their provincial associations.

Specialty pharmacy

A specialty pharmacy may work closely with physicians and patients on preparing a prior authorization claim. If your physician works closely with a specialty pharmacy, they will refer you for assistance in preparing your claim.

Your local pharmacy

If your prescribing physician does not tell you that the drug you are prescribed requires prior authorization, then you may learn this from your local pharmacy. If your pharmacy has told you that your prescription requires prior authorization, you should contact your physician’s office to let them know this. They may either assist you or direct you to a specialty pharmacy and/or PSP or DAN as noted.

You can find out more about the roles of these prior authorization stakeholders and patient organizations on the Resources page on this site.

Submitting a claim for review and approval

Once you are working with an individual or organization for help with your prior authorization claim, they will assist you to prepare and submit your claim. They will:

Coordinate all the information required from your physician and from you
Submit your claims documentation for review to your insurer on your behalf.

Today there is no electronic mechanism in place to submit your claim, so it will be sent to your insurer by mail or fax for review. If any further information is required, then you, your physician, or the organization who helped you submit your claim will be contacted by mail or fax.

The timeline for receiving a decision whether your claim has been approved will vary, but you can expect to wait at least 7-10 business days. You may receive a letter in the mail, or if the drug you have been prescribed is urgently needed, then you may receive a decision more quickly. If you have been working with a drug access navigator for your oncology drug(s) and the treatment is urgently needed, then you could receive a decision more quickly and you could receive a phone call from them.

Receiving your medication after approval

Once your claim has been approved, you may be directed to one of several locations by your insurer to receive your drug(s):

Your local pharmacy – if the drug you have been approved for is an oral medication your insurer may allow your medication to be dispensed by your local pharmacy.
A specialty pharmacy chosen by your insurer – the specialty pharmacy may be chosen either because the drug you have been prescribed is an injectable or infused therapy, or your insurer may have negotiated preferred pricing because the specialty pharmacy offers a volume discount.
In hospital – if the drug you have been prescribed is an injectable or infused therapy normally administered in hospital, particularly for oncology products, your drug may be administered in hospital.

If your claim is denied

If your claim is not approved, you will either receive written notice or you may receive a call from the group that helped you submit your claim. Your physician’s office or the group that helped you submit your claim will discuss appeal options or alternative medications for your condition. Review the final Patient section for more information on what to do if the drug you have been prescribed is not approved by your insurer.

Patient or Patient Group