Special Authorization

A broad range of prescription drugs are covered under the AFBS formulary, however, not all prescription drugs are covered. Also, certain drugs or categories of drugs may require a request for Special Authorization or coordination with your provincial drug plan. Typically, expensive new drugs providing minimal or no increased therapeutic value would not be added to the formulary.

The chart of Commonly Requested Special Authorization Drugs indicates many of the common areas where Special Authorization is requested and possible prescription drug alternatives which do not require Special Authorization.

Special Authorization may also be required in situations where the patient has not responded to first line therapies or where the drug may have potential for widespread use outside of approved use. From time to time new drugs are added to the Special Authorization Drug List register.

A Preferred Biologic Initiative was incorporated into the Special Authorization process November 1, 2012. A biologic drug is a substance that is made from a living organism or its products and is used in the prevention, diagnosis or treatment of cancer and other diseases. Biologic drugs include antibodies, interleukins and vaccines. Biologic drugs are typically prescribed when a patient does not respond to other drug therapies. For certain conditions including rheumatoid arthritis, some cancers, various blood disorders and the requirement for growth hormones there can also be considerable differences in the price charged by pharmaceutical companies when making biologic drugs available.

As part of the Special Authorization process certain higher priced biologic drugs may not be eligible for reimbursement when a lower cost and untried alternative is available. The Special Authorization Biologic Drug List provides additional details.

Special Authorization Process

If you are prescribed a prescription drug which requires Special Authorization, or discover at the pharmacy that your prescription drug requires Special Authorization, please follow the Steps to Obtain Special Drug Authorization as appropriate.

The Special Authorization process includes the completion of a brief questionnaire by your Medical Doctor outlining the medical justification for the prescribed medication. The questionnaire is reviewed by the clinical pharmacists at ClaimSecure who have been contracted by AFBS to provide this service and who follow accepted medical and pharmacological protocols. Their review is done on a completely confidential basis.

You will be responsible for any costs your Medical Doctor may charge for the completion of the Special Authorization form available here.

IMPORTANT: The Special Authorization Drug List and Commonly Requested Special Authorization Drugs are updated regularly, with new prescription drugs/medications added; criteria updated and, on occasion, drugs removed from Special Authorization.

This list is current as at the date noted. Every attempt has been made to ensure the accuracy of the information provided, however, if there are discrepancies the medical and pharmacological protocols in place at ClaimSecure will apply. ClaimSecure has been contracted by AFBS to provide prescription drug Formulary management, including the Special Authorization process.

Eligible Prescription Drug Expenses

A wide variety of prescription drugs are covered under the AFBS managed drug formulary. Only those drugs prescribed by a Medical Doctor or other health care providers as may be legislated by your provincial government and eligible under the AFBS formulary are covered. This includes prescribed diabetic supplies.

This is a generic drug plan. This means that a pharmacist will dispense the generic equivalent to the brand name drug when a generic equivalent is available. If you wish the brand name to be dispensed please alert your pharmacist. Reimbursement, however, will be based on the cost of the generic equivalent.

The cost of prescription drugs is comprised of two components: the ingredient cost and the dispensing fee. The AFBS managed drug formulary reimburses 70% of the usual and customary ingredient cost of covered drugs only. Dispensing fees may vary by pharmacy and also by the type of prescription being dispensed. You are encouraged to speak to your pharmacist about their dispensing fee policies.

Not Eligible Prescription Drug Expenses

• HIV/AIDS and multiple sclerosis medications are coordinated through your provincial health plan and are not eligible for reimbursement under the general AFBS formulary.
• Non-prescription drugs, over-the-counter medications and prescription drugs not included on the AFBS formulary are excluded from reimbursement.
• Dispensing fees.
• Atomizers, aero chambers, vaporizers, diagnostic aids.
• Infant formula.
• Vitamins (except injectable when not used in conjunction with weight loss).
• Dietary food/supplements, aids, minerals, or electrolyte replacements whether prescribed or not, except by law where a prescription is required for their sale.
• Rogaine and all other topical preparations of Minoxidil.
• Drugs not approved for sale by Health Canada.
• Drugs not considered to be therapeutically useful by the Canadian Medical Association or by the medical association of the Insured Person’s province of residence.
• Investigational or emergency release drugs.
• More than the customary supply of drugs prescribed by a physician or dentist or a 34-day supply (100 day supply for maintenance drugs), whichever is less.

Note to Senior Members (Members over 65)

Provincial Government Programs

At the present time, all provincial governments provide a prescription drug plan for seniors. Before turning 65, all senior members are encouraged to apply to their provincial plan for coverage.

A few provinces have instituted financial means tests before payment will be provided under the provincial plans. If you are denied access to the provincial drug plan, it is crucial that you advise the Arts & Entertainment Plan® administrator at AFBS immediately. Benefits may continue under the Arts & Entertainment Plan®.

If you are a senior member, the cost of prescription drugs is initially paid by your government program. Any eligible out-of-pocket amounts which are not paid by your provincial plan may be reimbursed through the Arts & Entertainment Plan®.

If you are a senior, we encourage you to work with your Medical Doctor who will be familiar with your province’s prescription drug program. The provincial plans also have special requirements and programs. You and your Medical Doctor need to apply to these programs first (for example Exception Drug Application, Limited Use or Cancer Care Program). If a prescription drug is not covered by the province, you and your Medical Doctor may make a special request through the Special Authorization process, to have the costs paid through the Arts & Entertainment Plan®.

Québec Residents – Special Note – Requirement to Provide Dependant Coverage

The Québec government requires that all residents have prescription drug coverage through a private insurance program, such as the Arts & Entertainment Plan® or Regis de L’Assurance Maladie du Québec (RAMQ). Your dependants do not qualify for coverage under RAMQ’s basic prescription drug program when you participate in a private insurance program. If you have eligible dependants who are under 65 you must insure them through the Arts & Entertainment Plan® when you are enrolling (or the date on which you acquire each new dependant, if later) if they are not already covered under another group insurance program. When providing protection to residents of Québec, AFBS must comply with the RAMQ formulary and deductibles. The impact of which is a 10% premium surcharge. When you complete your income tax, you will be asked to confirm that you have complied with the provisions of the Québec legislation.

Reimbursement Review

Prescription drug

If you believe there is a problem with your reimbursement amount, AFBS must be advised within 45 days of the date the Explanation of Benefits was issued. If, following this review, your concern remains, a written request for further review may be made and must be received at AFBS within 30 days of receipt of its initial review response.

Please remember that not all medically necessary services, supplies, prescriptions or dental procedures are eligible for reimbursement, there are claim submission deadlines and AFBS staff ensure a consistent approach to reimbursement, which is applied across all the insured membership.

If you wish to pursue the matter further complaints can be sent to the OmbudService for Life & Health Insurance.

Information about OLHI can be found at www.olhi.ca. Or contact them at (Canada) 1-888-295-8112, (Quebec) 1-866-582-2088.

Address:
802 -20 Adelaide St E, PO Box 29
Toronto, ON
M5C 2T6