Drugs that require Special Authority

SA approval may be granted for the following drug types. Consult the list of drugs that require SA approval.

Non-benefit drugs (exceptional)

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.

EDRDs (exceptional)

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.

Most (78%) of 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. It is provided on a last-resort case-by-case basis only, by agreement between SA and your prescriber. 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 for appeals