Special authorization process for prescription drug coverage
The University's Health Insurance Plan, administered by Medavie Blue Cross, provides prescription drug coverage according to the Blue Cross managed drug formulary, known as HealthWise.
HealthWise provides insured employees, retirees, and eligible dependents with immediate coverage for thousands of prescription drugs. Certain other medications require "Special Authorization" by Blue Cross. The first time a special authorization drug is needed, a one-time 30-day supply may be provided and reimbursed by Blue Cross. There are, however, certain special authorization drugs for which this "first fill forgiven" does not apply.
Subsequent refills, and drugs for which there is no first fill forgiven, will be subject to the special authorization process which involves the attending physician completing a Prescription Drug Special Authorization Request indicating the need for use of a particular drug. The information provided on this form is confidentially reviewed by Blue Cross and employees are usually notified of their assessment within 7 to 10 working days.
In the meantime, employees who might wish to know the status of their special authorization request can call the customer service centre at 1-800-667-4511.
"Special Authorization" appeals subcommittee
In response to concerns expressed by employees and retirees with respect to certain medications which are either not eligible, or have been declined, through the special authorization process, the Employee Benefits Committee of the Board of Regents established a Special Authorization Appeals Subcommittee in the mid-1990's.
This Subcommittee which is comprised of employee representatives and medical professionals within the University community, will, on a strictly confidential basis, consider individual requests for coverage of prescribed medications that have been officially denied coverage by Blue Cross through the special authorization process.
The Subcommittee will consider appeals made by employees/retirees, on an individual basis, provided the following conditions have been met:
- an official request for "special authorization" has been declined by the insurer;
- the medication bears a Drug Identification Number (DIN);
- the medication is prescribed by a licensed physician;the medication enables the individual to engage in their normal daily activities, including attendance at work, which would otherwise be impeded without the prescribed treatment;
- if a medication does not have official recognized approval for treatment of the condition for which it is being prescribed, sufficient published data supporting its use must be provided to the Subcommittee.
The effective date of coverage for medications approved by the Special Authorization Appeals Subcommittee is subject to the following timelines:
i) If an appeal is received by the Department of Human Resources within 90 days of the date that the medication was first denied at the pharmacy and the Special Authorization Appeals Subcommittee subsequently approves coverage for the medication, coverage will be effective from the date it was first denied.
ii) Otherwise, coverage for special authorization medication approved by the Special Authorization Appeals Subcommittee will be effective from the date of receipt of the appeal by the Department of Human Resources
For further information on the special authorization and appeal process, please contact the Benefits and Pensions Office of the Department of Human Resources at 864-7407 or by e-mail at firstname.lastname@example.org.