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This a free and interactive tool developed by the Canadian Skin Patient Alliance. The tool is designed to be used by patients who have received their prescription from their healthcare provider in the community and plan to fill it at a community pharmacy. The interactive drug coverage finder helps patients determine if they have coverage for the drug they have been prescribed by responding to a series of questions that are based on how public and private drug plans work together. Questions can be directed to drugcoverage@canadianskin.ca.
The article posted by the Canadian Breast Cancer network outlines some helpful steps to navigate what to do if your health claim has been denied. You can also find information for next steps if your claim has been denied under the Patient Information section of this site.
This is a website that provides healthcare professionals with information and resources about federal drug programs, reimbursement means for unfunded drugs, and patient support programs (PSPs). Other resources include insurance prior authorization claim forms, information on genomic testing for cancer patients, and the role of Drug Access Navigators (DANs).
Drug access navigator (DAN) associations represent the navigators who are experts in working with physicians, usually oncologists, and patients to facilitate access to medication from public and private payers.
They may have a diverse healthcare background including pharmacists, pharmacy technicians, nursing, or social worker. The associations can help patients find a DAN that works with in the hospital where they are being treated.
Here are links to some of the drug access navigator associations across the country:
If you do not know the drug identification number (DIN) of a medication you have been prescribed but you need to find it, then you can also refer to the Drug Product Database where you can search for the number (DIN).
Drug Identification Numbers (DINs) are an 8 digit number assigned to a drug by Health Canada. It is a unique number used to identify all drug products in Canada.
If you are looking to find out more details about insurance coverage about a specific drug, you may need to present the insurer with the appropriate DIN.
DINs can also be used to determine if the drug prescribed requires prior authorization. If you know the DIN number of your medications you can refer to them in inquiries to insurers, or for discussions with pharmacies, drug access navigators (DANs) or patient support programs (PSPs).
While there are similarities between drug coverage under group insurance policies and the claims process for drugs that are subject to prior authorization, sometimes referred to as special authorization, there will be some important differences. The following may vary between insurers and sometimes between group insurance policies:
Some insurers will have information about making a prior authorization claim on their website that is publicly available, including a list of drugs requiring prior authorization or access to claim forms for prior authorization drugs.
If a call is made to an insurer about prior authorization, then the insurer may ask for the member identification and group policy/contract number as well as the drug identification number (DIN) for the drug being prescribed, and the diagnosis. In most circumstances the patient must either be the individual making the inquiry or be on the line with the person making the inquiry to authorize the release of information.
The following is a list of major insurers and their resources available for PA.
Patient groups are non-for-profit organizations that can provide assistance, advice, and resources to patients diagnosed with a disease.
If you need support or you are having difficult finding a reimbursement assistance you can check with the patient group for your disease.
There are larger patient groups that can encompass many diseases and smaller patient groups that are specific to one disease. There are many different patient groups that exist.
Here are some prominent Canadian ones. Please note that this list is not exhaustive.
Patients are usually referred to a patient support program (PSP) by their physician for assistance in the claims process for specialty drugs that require prior authorization.
PSPs are typically paid by pharmaceutical companies to assist patients with claims and reimbursement for the drug(s) they have been prescribed, including exploring funding from private and public sources.
Many, but not all specialty medications will have patient support programs. For patients, PSP enrolment is only accessible with involvement from your physician or prescriber.
Some key PSP providers are*:
*This list is not exhaustive.
Regional PSP resources:
The following website lists available PSPs in British Columbia, their contact information, and supports they provide based on medication.
Prior Authorization is a multi-stakeholder process that involves more than just patients and payers.
Stakeholders involved in the Prior Authorization process include physicians, drug access navigators, patient support programs, specialty pharmacies, and insurers.
To find out more about different stakeholders and the role they play in the prior authorization process, click below.
If you do not have drug coverage through a private plan, there may be a special access program in your province that will cover the cost of your drug. Below is a list of provincial drug programs and their respective forms and contact information.
Specialty pharmacies dispense medications used to treat rare or complex diseases that either may be subject to prior authorization or may not be in stock at a community pharmacy. Medications subject to prior authorization may have short expiry dates, be required to be stored in a temperature-controlled environment, or may need to be administered by a medical professional in an infusion center.
Patients who are prescribed medications dispensed by a specialty pharmacy have usually been diagnosed with a disease that requires more complex treatment therapies. Specialty pharmacies also provide services that include treatment assessment, patient monitoring, and frequent communication with patient caregivers and health care practitioners. Infusion centres are also available at some locations.
If you are provider of service and are not included in our lists but would like to be, please contact info@simplifypriorauth.ca.
The Simplify Prior Authorization initiative is an advocate for education about prior authorization (PA) and improvement in current prior authorization practices and processes. If your organization is interested in finding out more, getting involved, or in sponsorship of this important initiative, please contact us via the link below.
