The prior authorization claims process begins when a drug is prescribed to a plan member. The prescriber, usually a physician, may or may not know that the drug they are prescribing will require prior authorization by the member’s group benefits provider. 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:
If the drug prescribed is not covered by any provincial drug plan and requires that the plan member submit a prior authorization claim for reimbursement, then the prescriber will also be required to prepare documentation that will support the claim. The plan member will also need to provide written information for their claim including:
If the plan member is not sure where to locate them, you will be able to help with their policy and possibly their certificate number.
Insurers can advise what claim forms are necessary. They may also refer plan members to one of the PSP organizations in the Resources page for assistance in completing forms and submitting the plan member’s drug(s) claim.
If the physician is familiar with the prior authorization process, they will probably have easy access to the claim form the plan member requires. They may also have staff to help the plan member and the physician complete the claim form, and attach the necessarily medication documentation. The physician may also refer the plan member to outside assistance to help with preparing their claim through a patient support program (PSP).
If the physician is not familiar with the prior authorization process, 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.
Help from outside the physician’s office – even with some guidance from a physician’s office, prior authorization and drug coverage for specialty drugs can be difficult to navigate. Most plan members will probably need some help from an expert in prior authorization who will work with a patient’s best interest in mind to achieve a timely and fair reimbursement decision.
Patient Support Programs are services delivered by PSP companies and funded by pharmaceutical manufacturers. The programs are designed to provide features and support for patients on specific medications. As advocates they help patients navigate the complexities of reimbursement.
PSPs may also have funds available to them through a patient assistance program to help with the cost of medication if the plan member does not have coverage elsewhere or if the drug is not completely covered either through a provincial drug plan or a group benefits plan. Programs that exist can be very specific in terms of criteria for enrollment. As such, the prescribing physician will be engaged to ensure that only those that qualify are referred.
The prescribing physician should be able to direct the plan member to the PSP for the drug they have prescribed. If it is not clear whether there is a PSP for the drug that has been prescribed, then the physician can contact the pharmaceutical manufacturer through their toll-free number or look online through the product name prescribed or on the manufacturer’s Canadian website. There are more tips on this under the Resources page of this website.
For oncology drugs, the physician may also refer the plan member to a drug access navigator (DAN), who are publicly funded, and will be able to help with enrollment if a manufacturers program does exist.
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 found in other diseases like Multiple Sclerosis and Cystic Fibrosis. If the plan member is being treated at a cancer centre, they should ask their physician if there is a DAN or someone in a similar role that can help them 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.
A specialty pharmacy may work closely with physicians and patients on preparing a prior authorization claim. If the prescribing physician works closely with a specialty pharmacy, the physician will refer the plan member for assistance in preparing their claim.
If the prescribing physician does not tell the plan member or they are not aware that the drug prescribed requires prior authorization, then the plan member’s local pharmacy may be the one to tell them that the drug requires prior authorization. In that case the plan member should contact their physician’s office and tell them that the drug prescribed requires prior authorization.
The physician or their staff may either assist the plan member or direct them to a specialty pharmacy and/or PSP or DAN as noted. Remember, you can find out more about the roles of these PA Stakeholders.
Once the plan member is working with an individual or organization for help with their prior authorization claim, they will provide assistance to prepare and submit the plan member’s prior authorization claim. They will:
Today there is no electronic mechanism in place to submit prior authorization claims, which means that the claim form and any other documentation will be sent by mail or fax for review. If any further information is required, then the plan member, the prescribing physician, or the organization who helped the plan member prepare and submit their claim will be contacted by mail or fax.
The timeline for receiving a decision on whether the claim has been approved will vary, but the plan member can expect to wait at least 7-10 days. The plan member may receive a letter in the mail, or if the drug prescribed is urgently needed, then they may receive a decision more quickly. If the plan member has been working with a drug access navigator for their oncology drug(s) and the treatment is urgently needed, then they could receive a decision more quickly and you could receive a phone call from them.
Once the claim has been approved, the plan member may be directed to one of several locations by the insurer to receive their drug(s):
Where the plan member will receive their medication may depend on several factors, including whether the drug is taken orally or infused.
If the claim is not approved, the plan member will either receive written notice or they may receive a call from the group that helped them submit their claim. Their prescribing physician’s office or the group that helped them submit their claim will discuss appeal options or alternative medications for their condition.
Review the next section for more information on what to do if the drug is not approved by the plan member’s insurer.