Special Authority (SA)

Last updated: November 16, 2022

Special Authority (SA) grants coverage to a drug, medical supply or device that otherwise would not be eligible for full coverage. Coverage is provided to patients in specific medical circumstances and depends on the patient’s PharmaCare plan rules, including deductible requirements.

 

SA requests must be made by a prescriber. Coverage is approved for patients who meet established criteria. In exceptional circumstances, SA may grant PharmaCare coverage to patients who don’t meet the pre-defined criteria, or for non-benefit items.

For certain drugs, some prescribers are automatically exempt or can enter a Collaborative Prescribing Agreement (CPA) that exempts them from submitting an SA request for each patient.

Full coverage differs from actual reimbursement. Actual reimbursement depends on a patient's PharmaCare plan rules, including Fair PharmaCare plan deductible and co-payment requirements, and is subject to pricing policies such as the Maximum Pricing Policy, the Low Cost Alternative (LCA) Program or the Reference Drug Program (RDP).

How to submit a SA request

SA requests can be submitted by fax or online (“eForms”) by most prescribers. It is easier and quicker to submit requests online, and decisions are generally returned more quickly. Refer to SA eForms to find out how to enrol and submit eForms.

Note: SA approval must be in place before a patient pays for a prescription. Coverage is not retroactive.

SA approval may be granted for the following drug types:

Limited coverage drugs

Medications that generally aren’t first-line therapies or have more cost-effective alternatives. Learn more about limited coverage drugs.

Non-reference drugs (partially covered)

Full coverage of non-reference drugs for patients who experience an adverse reaction or treatment failure on the reference drug.

Alternative products

If a patient cannot take a fully covered Low Cost Alternative (LCA) drug, prescribers can submit a SA request for full coverage of a brand-name drug in the same LCA category.

Originator biologics and biosimilars

Most originator biologics require SA approval. Those that have biosimilar alternatives are generally covered on an exceptional basis only, for patients who cannot take the biosimilar(s) for documented medical reasons. Refer to Biosimilars Initiative for health professionals.

Drugs not marketed in Canada

Health Canada’s Special Access Programme drugs are covered in exceptional circumstances only. Refer to PharmaCare Policy Manual, Section 6.2.

Non-benefit drugs

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. Exceptional approvals are usually of limited duration.

If faxing, requests must be submitted in two parts: the General SA Request form (with Sections 1, 2 and “Requested drug exemption” portion of Section 3 completed) AND a signed letter from the prescriber.

The letter must include:

  • 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
  1. Go to the SA drug list. The Generic Name column shows if the drug is limited coverage (LCD) or Reference Drug Program (RDP).
  2. Click on the drug name to view its coverage criteria page.
  3. Check if a Practitioner Exemption is available. If you're in an exempted group, you do not need to submit a SA request for your patient; their prescription will be covered automatically.
  4. Check if a Collaborative Prescribing Agreement (CPA) is available. ​If you enter into a CPA, you do not need to submit a SA request when prescribing according to the terms of the CPA.
  5. If you aren't eligible for an exemption or a CPA, find the correct form in the eForms platform or select the form linked at the bottom of the drug’s criteria page. Complete the form, documenting how your patient meets the coverage criteria. Submit the form using eForms, if applicable. If using fax, sign and fax the form to 1-800-609-4884 (toll-free in B.C.)

SA approval must be in place before the patient fills the prescription. Coverage cannot be provided retroactively.

Note: PharmaCare may use PharmaNet records to verify criteria have been met. If you provided samples for medication trials, documentation may be required.

The Low Cost Alternative (LCA) Program ensures B.C. residents get the best value on multiple-source drugs. Each LCA category consists of drugs with the same active ingredient(s) and the same strength. PharmaCare covers only those drugs that meet a set price.

If your patient is allergic or has an intolerance to the non-therapeutic ingredients used in the fully covered drugs within an LCA category, you can submit a Special Authority request for full coverage of another drug in that category (including an alternative generic brand of the same drug).

  1. See the LCA Master Spreadsheet that lists the multiple-source drugs that PharmaCare covers. In column F, a "P" indicates a partial benefit, and "F" indicates a full benefit. Only drugs marked "P" require SA approval to be covered.
  2. Complete a General Special Authority Request in eForms. If you aren’t yet enrolled to use eForms, complete the fillable PDF version: General SA Request (PDF, 656KB)
    Document your patient's clinical need for the drug. Be sure to list all the fully covered products they have trialed.
  3. Submit the SA request form on the eForms platform. If using a paper form, fax it to 1-800-609-4884 (toll-free in B.C.).

SA requests are prioritized by date received and by urgency. Once the request is processed, PharmaCare will notify you (the prescriber) of the decision unless:

  • You have indicated you did not require confirmation, or
  • The office fax number you gave is illegible or incorrect

Note: some drugs are eligible for auto-adjudication and will return an immediate decision. Refer to the SA drug list for the ones marked “Yes” in the Auto-adjudication column.

To ensure continuity of coverage, you may wish to schedule an appointment with the patient for re-evaluation so that, if a request for renewal is required, you can submit the renewal request at least 2 weeks before the expiry date.

The turnaround time for urgent SA requests is within 1 business day.

SA requests can be deemed urgent depending on medication required (this could include anticoagulants, oral antifungals, antibiotics, psychiatric and chemotherapy drugs, or for substance use disorder) and circumstances (e.g., hospital discharge, palliative treatment, MAiD, acute mental health or life-threatening conditions). 

Turnaround for regular requests is usually 10 business days. Submitting requests through eForms is strongly recommended, if applicable. Turnaround times are generally much quicker. Some drugs are eligible for auto-adjudication, which returns immediate decisions.

SA coverage is valid from the date the approval is entered in a patient's record on PharmaNet. Approval must be in place before a patient fills a prescription, as coverage won’t be provided retroactively. The duration of coverage depends on the drug and condition being treated.

 

BC PharmaCare reviews manufacturer drug submissions for PharmaCare coverage. The provincial review builds on work done by Health Canada and on recommendations made by the Canadian Agency for Drugs and Technologies’ (CADTH) national Common Drug Review (CDR).

Frequently, drugs submitted to the CDR are also reviewed by B.C.’s independent drug advisory committee, the Drug Benefit Council (DBC). The DBC makes evidence-based recommendations on whether drugs should be added to the PharmaCare formulary.

For information on the drug review process, refer to Drug review.

If you have questions about the drug review process, contact PharmaCare Formulary Management at drugreviewprocess@gov.bc.ca. If you have concerns about a drug product or the current criteria used to adjudicate SA drug coverage requests, please send an email to FM.GenericMailbox@gov.bc.ca.

Exceptional funding of EDRDs

On a case-by-case, last-resort basis, PharmaCare covers expensive drugs for rare diseases (EDRDs) that have an approximate annual cost of more than $100,000 per patient.