Drugs Requiring Pre-Approval (Special Authority)
PharmaCare covers some drugs only under specific medical circumstances. These drugs are “limited coverage.” They aren’t automatically covered because they may work for certain patients only, or they’re more expensive—but equally safe and effective—than other drug treatments.
If your prescriber believes your medical circumstances warrant the use of a specific limited coverage drug, they can submit a Special Authority request to PharmaCare explaining your medical situation. If PharmaCare agrees you meet the criteria for coverage, the Special Authority (SA) team will approve the SA request, and the drug will be eligible for full coverage, subject to the rules of your PharmaCare plan.
Note: SA approval must be in place before you fill your prescription for you to receive coverage. To find out if approval is in place, talk to your prescriber or pharmacist, or call 1-800-663-7100 (toll-free) or 604-683-7151 (from the Lower Mainland).
The limited coverage drugs in the categories below need to be approved by Special Authority to be eligible for full PharmaCare coverage. You can also consult these lists:
- List of drugs that require Special Authority approval
- List of items not eligible for PharmaCare coverage
Reference Drug Program (RDP)
PharmaCare fully covers the less costly drugs in a Reference Drug Program category. If you cannot take them (there can be more than one option in a given category), your prescriber can submit an SA request for full coverage of another drug in the category. See Reference Drug Program.
Low Cost Alternative (LCA) program
If you cannot take a lower cost version of a drug, your prescriber can submit an SA request for full coverage of another version of the drug. See Low Cost Alternative Program.
Psychiatric Medications Plan (Plan G)
Some drugs are fully covered under this plan only if your prescriber submits an SA request that is approved. See Psychiatric Medications Plan (Plan G).
PharmaCare fully covers donezepil to treat mild to moderate dementia if your prescriber submits an SA request that is approved. If you cannot tolerate donezepil, your prescriber can submit an SA request for full coverage of galantamine and oral rivastigmine (capsules only). See PharmaCare Coverage of Drugs for the Treatment of Alzheimer's Disease.
Non-benefit drugs (exceptional requests)
Non-benefit drugs are considered for coverage on an exceptional, last-resort basis, generally when all available PharmaCare benefit options have been tried without success or are unsuitable for the patient and no other coverage options (e.g., Extended Health – Blue Cross) are available.
Such requests must be submitted by the prescriber with a signed letter including:
- Patient diagnosis or indication
- List of all medications tried to date, including dose; duration of trial; and either patient response to medication OR, if medications not tried, reasons for not doing so
- Anticipated outcome(s) of treatment with requested drug (e.g., physical symptoms, quality of life/function)
- Confirmation that patient has no other insurance that would cover any part of the drug’s cost
- Any additional pertinent information
Exceptional approvals are usually of limited duration.
Special Access Programme
Physicians occasionally treat patients with medications not approved for sale in Canada in cases of serious or life-threatening illness when conventional therapies have failed, are unsuitable, are unavailable, or offer limited options.
Exceptional funding of EDRDs
Expensive drugs for rare diseases (EDRDs) are considered PharmaCare non-benefits, but in exceptional cases, coverage may be approved. Requests are assessed on a case-by-case basis.
Expensive drugs for rare diseases (EDRDs) are drugs with a very high per-patient cost — more than $100,000 each year— that treat rare diseases. All EDRDs are considered non-benefits, but some drugs and patients may be eligible for coverage on a case-by-case, last-resort basis.
EDRDs are generally associated with limited clinical information about both the disease and treatment. Because of this, therapies must be carefully reviewed by specialized clinicians. Clinician experts assess which patients are most suitable for a therapy, and ensure that the drugs are working for each patient.
If a patient meets the EDRD process patient eligibility requirements and their prescriber believes their medical circumstance warrants the use of a specific EDRD, the physician submits a request on behalf of their patient.
If you think you may be eligible, talk to your prescriber.
Actual reimbursement is always based on your PharmaCare plan rules. If you have not met your deductible or family maximum, you may need to pay all of part of the cost.
General coverage policies may limit the amount PharmaCare covers. For example, drug costs and dispensing fees vary from pharmacy to pharmacy. PharmaCare sets a maximum drug cost and dispensing fee it will pay.
>> Learn more about PharmaCare General Coverage Policies.
SA coverage begins the day the information is entered into PharmaNet, the computer network that links all B.C. pharmacies to a central database.
Ask your pharmacist to make sure SA is in place before you purchase the drug. Coverage cannot be provided retroactively.
SA coverage may be for a limited time (for example, 6 months) or indefinitely. If approval is for a limited time, your prescriber will need to submit another SA request before the current one expires.
Special Authority is going digital!
Prescribers will soon be able to submit SA requests online.
- Quicker approvals
- Automatic approvals (for some drugs)
- Improved tracking tools to help prescribers renew SA coverage without interruption
- Increased security of personal health information
- Better information for better treatment decisions
At the same time, the Ministry is continuing to increase patient access to personal health information, including details about their medication coverage. You can view your record of dispensed prescription medication online in the Health Gateway. See www.healthgateway.gov.bc.ca for more information.