Drugs requiring pre-approval for coverage (Special Authority)

Last updated: January 5, 2023

PharmaCare covers some drugs only under specific medical circumstances. They aren’t automatically covered because they may work for certain patients only, or because they’re more expensive than equally safe and effective drug treatments.

On this page: About Special Authority | Which drugs require Special Authority | If your request is not approved

Check your Special Authority request status on mobile and on desktop

About Special Authority

If your prescriber believes your circumstances warrant a limited coverage drug, they can request Special Authority coverage. If the SA team approves the SA request, the drug will be eligible for full coverage (subject to the rules* of your PharmaCare plan). 

SA coverage begins the day the information is entered into PharmaNet. SA coverage may be for a limited time (for example, 6 months) or indefinite. If approval is for a limited time, your prescriber will need to submit another SA request before the current one expires if you need to remain on the drug.

Note: Coverage cannot be provided retroactively. Find out if the SA request is approved before you purchase the drug: check the status in Health Gateway (steps below), talk to your prescriber or pharmacist, or contact us 

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:

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).

Alzheimer's disease

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).

Special Access Program

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.

PharmaCare coverage for these drugs is available only under exceptional circumstances through Special Authority. See section 6.2 of the PharmaCare Policy Manual.

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.

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.

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.

The great majority (78%) of Special Authority (SA) requests are approved. When they are not approved, this is often because the patient does not meet the criteria for coverage. You can look up the SA coverage criteria for your drug.

Note that sometimes an SA request is not submitted correctly, which can delay a decision. In this case, you may want to ask your prescriber if the form needs to be re-submitted. In other cases, the drug was never eligible for SA coverage, or even PharmaCare coverage. In rare cases, PharmaCare will make an exception and provide SA coverage for non-benefits or off-criteria. 

Appealing a Special Authority decision

To appeal a SA coverage decision, a prescriber faxes the original SA request with any pertinent additional supporting information to 1-800-609-4884.

Please note:

  • Exceptional coverage is rarely granted
  • SA approvals for exceptional coverage are provided on a last-resort case-by-case basis only, by agreement between SA and your prescriber
  • Requests for exceptional, last-resort coverage must be submitted in writing, in a letter containing the following details: baseline objective measurements that determine the patient’s response to treatment, duration of treatment, current dose, rationale for treatment, specific quantitative results considered to be indicators of success, and a list of all therapies that have been previously tried
  • Appeals are formally reviewed by the Pharmacist Review Committee
  • Retroactive coverage is not available. Prescriptions that are purchased without SA approval in place are not eligible for coverage
  • PharmaCare does not accept verbal requests or appeals

Note: Requests submitted digitally will show up immediately. If your prescriber faxes in the request, it may not show up in Health Gateway for up to 2 weeks. 

1. Register for an account and log in at www.healthgateway.gov.bc.ca
2. Click on "Health Records" in the Dashboard.

3. Use the "Options" drop-down menu to filter your results.

4. Select "Special Authority," then click "Apply."

5. Your Special Authority records will appear and show whether your request has been received for processing: 

If you were approved for coverage, it will display as "Status: Approved."

Note: Requests submitted digitally will show up immediately. If your prescriber faxes in the request, it may not show up in Health Gateway for up to 2 weeks.  

1. Register for an account and log in at www.healthgateway.gov.bc.ca
2. Click on "Health Records" in the Dashboard.

3. Use the "Options" drop-down menu to filter your results.

4. Select "Special Authority," then click "Apply."

5. Your Special Authority records will appear and show whether your request has been received for processing: 

If you were approved for coverage, it will display as "Status: Approved."

 

*Actual reimbursement is always based on your PharmaCare plan rules. For example, if you haven't met your Fair PharmaCare deductible or family maximum, you may pay some or all of the cost.