When is a Prescription Drug A Specialty Drug?
Most prescription drugs, particularly those that have been available for a long time, will be reimbursed by almost all group health plans. These are not usually specialty drugs. You or a member of your family who is insured under your plan may receive a generic drug as a result.
A brand drug and generic drug are essentially the same, although they may look a little different. These prescriptions can typically be filled at your local pharmacy using your prescription drug card as identification to confirm your insurer, your policy number, and your certificate number, whether you are the primary plan member or included on the plan as a spouse or a dependent.
Specialty drugs are newer, more expensive drugs whose price is often $10,000 or more annually per patient and may not be available at your local pharmacy. They may be on the list of drugs identified by your insurer that require preapproval through their prior or special authorization (PA).
Specialty drugs are typically used in the treatment of more complex conditions such as cancer, rheumatoid arthritis, psoriasis, Crohn’s disease, multiple sclerosis, and other autoimmune diseases. It is common for insurers to restrict access to these drugs so that only plan members with a specific medical history, disease profile, or those who have tried and failed to respond to other less expensive therapies, have access to more expensive drugs. Insurance providers have specific criteria that must be met to cover a specialty drug to treat a specific condition, and these criteria can vary between insurance providers.
Biologic drugs or biosimilars are usually specialty drugs. A biologic drug is the originator drug and the biosimilar is similar but not 100% the same as the originator biologic. Biosimilars tend to be less expensive than biologic drugs. While they are not used interchangeably like brand and generic drugs, a biosimilar may be prescribed by your physician.
Is my prescription for a specialty drug?
The drug you or your family member have been prescribed is probably a specialty drug requiring prior authorization (PA) if one or more of the following applies:
- If you have been told that the drug is not immediately available to you because you must try another, usually less expensive, medication first.
- If you and your prescriber, usually a physician, must complete a claim form(s) and provide medical evidence to support your claim before your insurer, or the organization authorized to review your claim on behalf of your insurer (payers), will consider reimbursement of the drug(s) you have been prescribed.
If you are not sure if you or your family member have been prescribed a specialty drug requiring prior authorization you can check with your prescriber, (usually your physician), your pharmacist, or the insurer that manages your group benefits plan. Before checking, be sure to have your group policy number and certificate number handy and be aware of the drug name and what condition the drug has been prescribed to treat.
Finding Claim Forms
If your prescribing physician does not have the claim form(s) you need to complete and/or sign, then your insurer will be able to tell you how to find claim form(s) you need. When you contact your insurer for the prior authorization claims form, you should have your policy and certificate numbers handy, and you should know the name of the drug you have been prescribed and the disease that the drug will be used to treat. Knowing the disease is important because claim forms can vary by condition for specialty drugs.
You can find links to insurers and their prior authorization claim form lists under Resources on this site. Drug Access Canada also links to prior authorization forms for private insurers as well as other resources related to prior authorization.
If the drug(s) you have been prescribed requires prior authorization, then you and your prescribing physician will need to complete sections of the form(s). You may need assistance with the process of submitting your claim for reimbursement. This website contains information that is designed to help you. This site will explain the claims process, the stakeholders in the process, and who can help you prepare and submit your claim, including who can help if your claim is denied/not approved by your insurer.
In the Resources section of this site, you will find several links that can help you determine whether your drug will be covered by your group plan or a provincial drug plan.
If you need further guidance, you can contact Simplify Prior Authorization by completing the Contact Us information on this website.