Prior Authorization is a program that is used in conjunction with a formulary.
It allows plan sponsors to limit the use of specific drugs by requiring that
patients obtain prior authorization before the drug is covered under the plan.
Targeted drugs are removed from the formulary and claims for these drugs are
eligible for reimbursement only if clinical criteria are satisfied. The clinical
protocols used in the Prior Authorization Program are based on guidelines that
are currently in place in Provincial Formularies as well as independent review
sources. As a result, these protocols are expected to be reasonably acceptable
to both physicians and pharmacists. This program is designed so that people
who meet the criteria outlined on the respective Prior Authorization forms receive
the medication they require.
The Prior Authorization Program may reduce claims costs by ensuring that members
receive the most appropriate and cost efficient drug therapy. At the same time,
it minimizes employee relation concerns by using only credible and accepted
clinical criteria to establish authorization levels. Should an employee choose
not to submit an exception request or if the request does not meet the pre-determined
criteria, the claim will be rejected.
This program is dynamic. TELUS Health Solutions may add drugs to the program or change
the protocols, if deemed necessary. This allows us to maintain the protocols
to reflect changes in prescribing practices as new medications and new information
become available. It also ensures that the protocols are appropriate with respect
to the ever-changing drug benefit marketplace.
Frequently Asked Questions - Prior Authorization