Has this ever happened to you? You’re at the pharmacy to pick up your prescription and you’re told it must go through the special authorization process. If you’ve never heard of “special authorization”, we can help you with that.
What is special authorization?
Special authorization is a mechanism used by insurance providers to process access to certain prescription drugs according to defined clinical criteria. Special authorization request forms are completed by healthcare providers on your behalf. Special authorization is a crucial management tool for benefits providers in that it helps to ensure that drug benefit plans are effective and can continue to operate well over time.
Why does special authorization exist?
Not all medications are automatically covered, especially those that might have specific uses. The special authorization process helps control costs while maintaining health outcomes. It does this by making sure that specific medications are only covered for plan members who meet certain clinical requirements. This process strikes a balance between providing access to necessary medications and managing plan costs, but it doesn’t regulate prescribers’ practices, such as determining the best treatment options for patients or ensuring the appropriate use of medications.
If your medication is denied through the special authorization process, it simply means that coverage isn’t available under the specific drug plan. However, you still have the option to use the medication at your own expense.
For more information on the special authorization process, please refer to the link: Health benefits | Alberta Blue Cross®
How does it work?
If you’re starting on a new prescription drug that requires special authorization, your healthcare provider will need to fill out a special authorization request form and submit it to Alberta Blue Cross for review. The information provided will be confidentially reviewed against the clinical coverage.
Sometimes, the initial request might not have all the information required to make a decision on coverage under your plan. In this case, we’ll contact your healthcare provider to request additional details. This will put the decision into a “pending” status.
There are two possible outcomes: an approval (meaning the medication will be covered), or a denial (meaning the medication will not be covered under your plan). We’ll let you and your healthcare provider know the outcome of your request. If approved, you’ll receive coverage based on your group or individual drug plan coverage rules.
What happens if the request is denied?
If your request for special authorization is denied, it means the medication doesn’t meet the clinical coverage criteria under your plan. But this doesn’t mean you don’t have any other options. Ask your healthcare provider if there are alternative treatments available to you.
How long does the special authorization process take?
The time it takes to process a special authorization request can vary, but Alberta Blue Cross strives to handle each request as quickly as possible—especially for medications that are urgently needed. Once all required information has been received, the majority of drug authorizations are processed no later than 14 days.
Which drugs require special authorization?
Many specialty, biologic or expensive drugs require special authorization. To check if your medication requires special authorization, you can:
- sign in to the Alberta Blue Cross member site at ab.bluecross.ca and use the drug look-up tool, which you can find by selecting “Benefits” and then “Drug coverage”
- speak to your healthcare provider for more information or
- contact Alberta Blue Cross
How do I apply for special authorization?
Your healthcare provider must complete a special authorization form and submit it to Alberta Blue Cross for review. They may charge a fee for completing the form. This fee is not covered by your plan, but these fees can be submitted as an eligible medical expense, should your plan include a Health Spending Account.
Can I check the status of my special authorization request?
To ensure you receive email notifications on the status of your special authorization, you’ll need to register for access on the member site.
- To check the status of your special authorization request, please wait until you receive the email from us or at least 10 business days.
- Sign into the Alberta Blue Cross member site at ab.bluecross.ca
- Select the “Special authorization” tab in the “Benefits” section under “Drug coverage”.
– If the special authorization request is approved, you and your doctor will be notified. All coverage rules (such as co-payments, deductibles, and maximums) of your drug plan will apply.
– If the request for special authorization is denied, you and your doctor will be notified. Any questions regarding this decision should be directed to your health care provider. Our specialists are not medically trained to answer these inquiries.
– If additional information to process the authorization is required, the status will show as pending.
You can view all letters associated with your special authorization on the member site as well.
When a special authorization request is approved, how long does it last?
Special authorization is granted for a specific approval period, which varies from drug to drug. When you receive the decision notification, it will provide the period of time the special authorization is approved for.
Select medications are eligible for auto renewal, where an approval remains in place as long as you continue to regularly take the drug. For other drugs, if continued treatment is necessary beyond the approval duration (for example, 12 months), your healthcare provider will need to reapply for special authorization prior to the termination of the original approval.
You will receive an email from us prior to your termination date letting you know that if you still need your special authorization drug, you will need to have your healthcare provider resubmit a new form. You can also check the termination date of your special authorization on the Plan Member sign in | Alberta Blue Cross® Personal & group health benefits
Questions?
Navigating the special authorization process can be challenging, but Alberta Blue Cross is here to support you. Our goal is to make sure you understand the process and next steps.
