Buying medication at the pharmacy is getting more complex. If you are on high-cost medication or a specialty medication, the information below will help. Your pharmacist may say you need your physician to fill out a special form to send to your insurance carrier for approval.
Your insurance plan will limit any first claim for medication to as little as 7 days. If you move to a new insurer, they see your existing medication as a new claim. Here’s how you can fix it:
- The pharmacist can call your insurer and confirm your medication is a long-standing prescription and works for you. The insurer will then give them a code to allow the normal supply. This may take longer than usual. Allow yourself extra time. Go to the pharmacy during normal business hours as this is when the insurer will have people available to help fix the issue.
Special Authorization Process
Special Authorizations are done to protect you. Usually, they accompany medications that are very expensive. This is a process simply meant to ensure you are as safe as possible at as low a cost as possible and follows the provincial authorization rules. (The average plan has you paying about 20% of the cost. I would rather pay 20% of $500 / year rather than 20% of $50,000 / year.)
- Even if you have a medication that has been approved by your old insurer, you may need to submit a new letter to your new insurer. Do not wait till you need your refill. Call us ASAP to see if we can assist with the process. Calling us ahead will tell you what you need to know and may allow us to help.
An example is a medication call Ozempic. This medication needs Special Authorization. It was originally approved by Health Canada for diabetes. It is also commonly used for weight loss even though it is not approved by Pharmacare. As such insurers will not pay for it when prescribed for weight loss.
- Sometimes, Special Authority for one medication will remove the Special Authority for another. In that case, the best action is to work with your prescriber to remove one or pick the highest cost drug to have coverage for and pay out of pocket for the other.
This may be a good opportunity for a medication review with your pharmacist who will look at the two meds critically and give some thoughts on which is better for your needs.
Register for Pharmacare (BC Residents)
All insurers are second payors to free government programs. Since Pharmacare is a no charge program in BC, you must register. If you do not, you can expect your insurer to decline coverage for medication around the $700 mark. Show your pharmacist your Pharmacare ID card as soon as you can and call your insurer to register the number on your account.
For a list of medications that require Special Authorization from Pharmacare, please visit:
Note: This list is not comprehensive and may change with no notice.
Jay Nadler, Employee Benefit Specialist.
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