Some prescription drugs require prior authorization before making a claim.
So, what exactly is prior authorization? What drugs fall into this category? And why? How to request authorization? We answer all your questions.
Questions on everyone’s mind
What is a prior authorization drug?
Also called an exception drug, it’s a drug we need to authorize before it can be reimbursed to you.
Generally speaking, a drug requires prior authorization when:
- it's expensive
- treatment is complex or specialized
- it poses potential health risks
- there are less expensive yet effective therapeutic alternatives
- it could be abused or misused
What is prior authorization?
It’s the process we use to determine if a drug can be reimbursed through your insurance plan. First off, your physician fills out a form to confirm that the prescribed drug will be correctly used. Then, we ensure the drug meets our authorization criteria.
These criteria are based on recommendations from various provincial bodies responsible for assessing prescription drugs and follow Health Canada guidelines.
What are the advantages of prior authorization?
It optimizes the cost-effectiveness of expensive drugs by guaranteeing that plan members receive medically appropriate and necessary treatment.
Prior authorization is therefore beneficial for both companies and their employees. Not only can it lower the costs in a group insurance plan, it provides insured persons with well-managed care.