6.3 Special Authority Coverage

General Policy Description

For some drugs, PharmaCare requires the patient’s health care provider to submit a request for Special Authority (SA) approval in order to be eligible for coverage.

In these cases, PharmaCare coverage is applicable only to prescriptions purchased after Special Authority has been granted and entered in PharmaNet. No retroactive coverage is available.

Policy Details

Special Authority approval grants full or partial PharmaCare coverage for a drug that might otherwise not be covered or be covered only partially.

The rules of a patient's plan, including any deductible and co-payment requirement, apply even if the patient is granted Special Authority coverage.

Special Authority approval does not exempt the drug from PharmaCare pricing policies such as the PharmaCare Maximum Pricing Policy, the Low Cost Alternative Program or the Reference Drug Program, unless the Special Authority has been specifically granted for that purpose.

Special Authority coverage cannot be provided retroactively. Special Authority approval must be in effect on PharmaNet when the patient purchases the prescription.

Special Authority may be granted for

  • A Limited Coverage medication
  • An alternate product for patients unable to use the low-cost alternative (due to allergy) or reference drug product (due to adverse reaction or treatment failure)
  • Drugs that are not marketed in Canada (i.e., Health Canada "Special Access Programme Drugs"), in exceptional circumstances only

Although PharmaCare Special Authority Requests are normally approved only for patients who meet established criteria, under exceptional circumstances, PharmaCare may cover patients who do not meet the pre-defined criteria when a request is made by an appropriate health care practitioner.

PharmaCare applies the same coverage criteria to certain groups of similar medications. When PharmaCare approves Special Authority coverage for one medication in the group, coverage is automatically provided for all the drugs in that group. If the patient later requires another medication in the same group, no additional Special Authority request is necessary.

When a medical practitioner prescribes a medication similar to one the patient has taken before, the practitioner or pharmacist can contact the PharmaNet Help Desk to see if the drug is part of a "super category" for which the patient already has Special Authority coverage. If it is, another Special Authority request will not be required for the new medication.

Items not generally available for Special Authority coverage include drugs and medical supplies and devices listed as Examples of Items/Services that PharmaCare Does Not Cover.

Some third-party insurers cover a product only if PharmaCare has granted a Special Authority for the product and the Special Authority was granted before the prescription was filled (i.e., they do not provide retroactive coverage). All inquiries regarding retroactive coverage by a third-party insurer should be directed to the specific insurer, not to PharmaCare.

On occasion, PharmaCare grants a Special Authority exemption to a medical practitioner or specialty.

A Special Authority exemption applied to a specific medical practitioner provides coverage for identified drugs for all the patients of that practitioner.

A Special Authority exemption applied to a specialty group of medical practitioners provides coverage for identified drugs for all the patients of all the practitioners in that specialty group.

Although PharmaCare carefully reviews requests for such exemptions, only a limited number of requests can be approved.

Assumed SAs reduce the number of SA requests medical practitioners are required to submit. The resulting decrease in workload improves processing times for other requests. 

For specific medications, if the medication is initially prescribed by a medical practitioner who has a Special Authority exemption, in most cases, the patient is automatically granted indefinite Special Authority (SA) approval. If so, a general practitioner or other medical practitioners will not need to submit a Special Authority request to maintain the patient's coverage.

Before issuing a prescription for medications eligible for an Assumed SA, a medical practitioner can check the patient's chart to verify that the medication was initially prescribed by a specialist. If it was, the practitioner can choose not to submit a Special Authority request.

Each criteria page indicates whether or not an SA exemption exists for a specific medication.

Some pharmacies, usually hospital pharmacies, deal with patients in specialty areas. Occasionally such a pharmacy (e.g., British Columbia Children's Hospital) is granted a Special Authority exemption.

When dispensing a particular drug that would otherwise not be a full benefit, a Pharmacy Special Authority exempts patients of that pharmacy from requiring individual Special Authority approval.

A drug dispensed under a Pharmacy Special Authority becomes a full benefit for all patients of that pharmacy, subject to PharmaCare pricing polices and the usual rules of each patient's PharmaCare plan, including any deductible requirements.

Rural or remote areas

[Amended August 24, 2016] Pharmacists can call the PharmaNet Help Desk to request Special Authority Exemptions to the PharmaCare 30-day maximum supply limit for patients residing in rural or remote areas for whom travel to the pharmacy is a significant barrier.

The exemption will be entered into PharmaNet as a one-day Special Authority.

Chronic conditions

Medical practitioners can submit a Special Authority, requesting that a patient be exempted from the 30-day maximum supply policy for 'short-term' drugs if the patient has a chronic condition.

Short-term drugs include all narcotics, all antibiotics, antifungals, sedatives, sleeping pills, barbiturates and all medications in the Palliative Care Drug Plan (Plan P) Formulary.

Approval may be granted to allow a maximum 100-day supply.

 

Procedures

Obtaining Special Authority for drug coverage for an individual patient

A medical practitioner submits information outlining the exceptional needs of the patient by

  • Submitting a Special Authority Request form by fax, or
  • By telephone, using the Practitioner Special Authority phone line

Obtaining Special Authority exemption for patients with chronic conditions

If a patient has a chronic condition requiring repeated treatment with a short-term drug, their medical practitioner can submit a Special Authority asking that the patient be exempted from the 30-day maximum supply policy for 'short-term' drugs. 

If Special Authority coverage is granted, an entry is made in PharmaNet allowing a maximum 100-day supply of the specified drug.

Obtaining Special Authority exemptions for patients in rural or remote areas

[Amended August 24, 2016] Pharmacists can call the PharmaNet Help Desk to request Special Authority Exemptions to the PharmaCare 30-day maximum supply limit for patients in rural or remote areas for whom travel to the pharmacy is a significant barrier.

The exemption will be entered into PharmaNet as a one-day Special Authority.

 

Tools and Resources