August 16, 2024
Most drugs that are not “over the counter” with the exception of anti-obesity and anti-smoking drugs are covered under the OSSTF Benefits Plans. However, to help keep our plans sustainable and affordable some prescriptions require prior authorization(pre-approval) to be covered under the OSSTF Benefit Plans.
What is Drug Prior Authorization?
Some prescriptions (such as medications with multiple uses or specialty drugs) require prior authorization (pre-approval) to be covered under the OSSTF Benefits plans.
Specialty drugs are used to treat complex, chronic or life-threatening medical conditions, and often have a higher cost.
Some of the more common conditions and medications requiring prior authorization include:
If your prescription requires prior authorization, it cannot be covered by the OSSTF Benefits plans until it’s approved by OSSTF Benefits drug prior authorization service provider which is currently Cubic Health’s FACET team.
Cubic Health and the FACET Team
Cubic Health is an independent third-party organization, that adjudicates specialty drug prior authorization requests for the OSSTF Benefits plans, through their FACET program and team of licensed clinical pharmacists.
Cubic Health and the FACET team are unbiased and have no financial incentive in their decision-making. A pharmacist(s) – with expertise in the condition being treated – objectively assesses each medication based on cost-effectiveness and up-to-date evidence-based clinical criteria for the condition in accordance with provisions outlined in the OSSTF Benefits Plan document.
How do you find out if a Drug Requires Prior Authorization?
Your pharmacist should advise you (or your dependent) if prior authorization is required.
If you are unsure about whether a medication requires prior authorization, login into the OTIP member portal and use the Drug Lookup Tool in My Claims to search for the name of your medication. The Drug Lookup Tool will provide details on whether the medication is immediately covered by your plan or if it requires prior authorization.
How to Request Prior Authorization
If the Drug Lookup Tool or your pharmacist indicates that a drug prescribed for you or an eligible dependent covered under the OSSTF Benefits plans requires prior authorization, follow the steps below:
Any personal information provided by you or your doctor to FACET as part of your prior authorization request is confidential. FACET will communicate their decision directly with you (or your dependent) and your doctor.
How long will it take for the FACET team to make a decision?
If all the information required by the FACET team is provided, a decision about the coverage of a drug requiring prior authorization will be made within two business days. Where additional information may be required, a decision will be made within five business days 99% of the time.
Once the prior authorization decision has been made, you and your physician will be notified by the FACET team and provided with the specific rationale used to make the final decision.
If a drug cannot be approved, the FACET team will discuss alternatives with you and your doctor.
If a drug is approved (or conditionally approved) for coverage under the OSSTF Benefits Plans, FACET will advise Manulife. FACET approvals are valid for one year.
For more information about the FACET drug prior authorization program, visit the FACET website www.facetprogram.ca/en to view the Frequently Asked Questions (FAQs) or contact FACET directly using the contact us link.
Who is MemberRx?
MemberRx
The OSSTF Employee Life and Health Trust (OSSTF ELHT) has designated MemberRx as the exclusive pharmacy distributor for certain high-cost specialty medications. This means that certain specialty drugs will only be covered under your OSSTF ELHT benefits plan if they are dispensed to you by MemberRx.
Through the MemberRx pharmacy model, expensive pharmacy and specialty medication costs will be minimized which will help in supporting the sustainability of the OSSTF ELHT benefits plan so that the OSSTF ELHT can continue to provide the best coverage for the specialty medications that plan members and their eligible family members need, at the best value.
Questions?
The information in this document is provided by OSSTF Benefits for general information only. OSSTF Benefits endeavours to have all information current and accurate. We make no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, or suitability of the information included. All information is subject to change without notice.
The information contained in this website is for general information purposes only. The information is provided by OSSTF Benefits and while we endeavour to keep the information up to date and correct, we make no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, suitability or availability with respect to the website or the information, products, services, or related graphics contained on the website for any purpose. Any reliance you place on such information is therefore strictly at your own risk. All information on this website is subject to change without notice.