Special Authority

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.

 

Special Authority 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.

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

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).

New!Special Authority requests can be submitted online (“eForms”) by some prescribers. eForms are quicker and easier to submit, and decisions are generally returned more quickly.


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. See 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 Special Authority request for full coverage of a brand-name drug in the same LCA category.

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.

 

Drugs not marketed in Canada

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

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. See Biosimilars Initiative for Health Professionals.

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

 

Some prescribers can now submit SA requests online, using SA eForms.  An eForm is an online version of a paper form. It’s more secure and generally submitted and returns decisions more quickly than faxes. For certain medications, requests that previously took up to 10 days can be approved within hours.

SA requests can be submitted online through the Provincial Health Services Authority (PHSA) eForms platform. They may also be submitted directly from an electronic medical record (EMR), if applicable.  

Watch a short tutorial on how to submit an eForm.

Advantages of eForms:

  • Auto-adjudications for certain medications
  • Notifications for received submissions
  • Many form fields complete automatically (e.g. prescriber information)
  • Criteria easily checked off
  • Less back-and-forth with the SA team, because of improved data collection
  • Patients can track the status of the request in Health Gateway

Faxes

You can continue to fax in SA requests, if needed or if you cannot currently access eForms. However, faxed requests won't be auto-adjudicated and your patients won't be able to readily track the request in Health Gateway. Faxes are also less secure than eForms, take longer to submit, and are adjudicated more slowly.

Health Authority User Access

If you are a clinician or pharmacist and work for or are associated with a health authority, you can use eForms. Ask your supervisor about enrolment procedures specific to your health authority.

Generally, you would begin by completing the eForms enrolment spreadsheet (XLS) for an individual or group request. All fields are required. Email the completed spreadsheet to eFormsenrolment@phsa.ca, cc-ing your manager or health authority leadership. Once approved, you will receive an email confirming your access to eForms, with a link and instructions. If you submitted a group request, please distribute the information to each person accordingly.

Community Practice User Access

If you are a prescriber and work in a private community health practice, you will soon be able to enrol through the Provider Identity Portal for access to eForms. Details to come. 

EMR Community Practice Access

Prescribers who use EMRs will be able to access eForms through their EMR software to submit SA requests. Speak to your EMR vendor for specific information about your eForms integrations and access.

Watch this space and the PharmaCare Newsletter for updates. For questions or enrolment support, contact SATransformation@gov.bc.ca

 

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, see Drug Review.

If you have questions about the drug review process, please contact PharmaCare’s Formulary Management branch 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.

Thank you

The SA team wants to express our appreciation to pharmacists, prescribers, healthcare partners and patients for their patience with the current backlog. The SA team is working hard to make sure that patients in B.C. benefit fully from Special Authority coverage.