How does it work?

If a member from a group that has chosen this program goes to the pharmacy with a prescription for a "targeted drug", it will be declined with the message "Prior Auth required". This particular message signals to the pharmacist that this drug requires prior authorization. The member can then go to the insurer's website or another designated website to print a copy of the appropriate Prior Authorization form. Once their physician completes the form, the insured may submit it by fax or mail to Emergis. Our Pharmacy Services Department then reviews the form(s) and determines if the individual qualifies for the respective authorization. If approved, Emergis loads an exception for that individual to our system and notifies the member by telephone, letter, fax or e-mail (as indicated by the individual on the prior authorization form). The pharmacy name and phone number are optional information the member may supply on the form. Future prescriptions for this medication will subsequently be filled electronically at the point-of-sale. If the review team requires more information or declines the form, they will advise the member as indicated.

How do plan members apply for coverage under the Prior Authorization Program?

As a member of the drug plan there are certain drugs that must be applied for, before you can make a claim. Consult our list of drugs that require prior authorization (see below). Prior Authorization Forms are available from a designated website as indicated by your employer. They are also available on the Assure Claims Forms page.

Prior Authorization Forms

The following is a list of drugs that require Prior Authorization and are not automatically covered by our plan. Please note that this program targets selected drugs for each therapy.

• Anti-depressant therapy - Wellbutrin (and generic bupropion)
• Anti-inflammatory therapy - Celebrex
• Anti-obesity therapy - Ionamin , Sanorex, Tenuate and Xenical
• Asthma - Xolair
• Benign prostate enlargement therapy - Avodart and Proscar (and generic finasteride)
• Biologic response modifiers (rheumatoid arthritis, Crohn's disease and/or chronic plaque psoriasis drugs; may have expanding indications such as but not limited to psoriatic arthritis, ankylosing spondylitis and/or ulcerative colitis. Please refer to the individual Prior Authorization Form) - Actemra, Amevive, Cimzia, Enbrel, Humira, Kineret, Orencia, Remicade, Rituxan, Simponi and Stelara
• Cancer therapy - Afinitor, Gleevec, Iressa, Nexavar, Revlimid, Sprycel, Sutent, Tarceva, Tasigna, Temodal, Thalomid, Tykerb, Votrient, Zolinza and Zytiga.
• Erectile dysfunction therapy - Cialis, Levitra, Staxyn and Viagra
• Migraine headache therapy - Amerge (and generic naratriptan), Axert, Frova, Imitrex (and generic sumatriptan), Maxalt, Relpax and Zomig
• Multiple sclerosis therapy - Gilenya, Tysabri
• Muscle or nerve disorders - Botox and Xeomin
• Osteoporosis - Forteo
• Pulmonary arterial hypertension therapy - Adcirca, Revatio
• Rare Diseases – Catena, Kuvan, Revolade, Zavesca
• Ulcer-heartburn therapy - Dexilant, Nexium, and Tecta

What can I do to ensure efficient processing of my application for coverage under the Prior Authorization Program?

Please make sure you are using the correct Prior Authorization drug form, and check to make sure all sections are completed before submitting it - e.g. all applicable criteria check box (in physician's Section B), your physician's signature with the date (in physician's Section B) your own signature with the date (in patient's Section A of the form). Please print clearly all contact information (in patient's Section A of the form). Any incomplete form will delay processing of the request.

Follow these easy steps to complete the forms:

1. Select the drug name you require from the list of Prior Authorization Forms.
2. Click on the drug name to open the form (in pdf format) and print the form.
3. Complete the patient information section, sign and date the form.
4. Have your doctor check all the appropriate box(es), complete any requested information that applies to your condition and have your doctor sign the form.
5. Fax the form to Emergis at the number indicated at the top of the form.

Do not forget to sign and date the form and have your doctor sign and date the form. Any unsigned forms will delay processing of the request.

All information is kept strictly confidential.

How will I know if I qualify to have my drug covered under the plan?

Your form will be reviewed and if complete, you will be notified within two business days whether or not your application has been approved. If the drug is approved for coverage and you paid cash for the first drug claim, you can submit this original paper drug claim to your insurance carrier for reimbursement. Once you have been approved you will be able to use your drug card to purchase future prescriptions for the approved drug at your pharmacy. If you are not approved for coverage, future claims for the drug will not be covered by your drug plan. You will need to pay for these future prescriptions yourself or ask your doctor to prescribe a different drug that is covered by the plan.

What guidelines are used to determine if a drug should be covered under the plan?

The guidelines used are similar to the guidelines established by provincial drug plans as well as the information on the Product monograph inserts that come with your medications. Therefore these guidelines should be familiar to your physician.

Who can I ask for more information?

If you have any questions about the Prior Authorization Program, please contact your plan administrator.