®The Blue Cross symbol and name are registered marks of the Cana-dian Association of Blue Cross Plans, an association of independent Blue Cross plans. Licensed to ABC Benefits Corporation for use in operating the Alberta Blue Cross Plan. ABC 40485/82195 2009/06

Special Authorizationfor select drug products

What else do I need to know about Special Authorization? Special Authorization is provided for selected drugs via a number of processes. These include:

1) regular Special Authorization where the selected drug must be requested by your doctor and coverage is provided for a period when criteria have been met. At the end of the approval period, a special authorization renewal request must be made for continued therapy.

2) an “auto renewal” process to allow for continued treatment with selected drugs. The Special Authorization remains in place as long as you continue uninterrupted therapy.

3) the “Step Therapy” process, through which coverage is provided in instances where other drugs (commonly referred to as first-line therapies) were tried and not effective, or to which you experienced allergic reactions or intolerable side effects. Coverage may also be provided for the Step Therapy drug if you have a medical condition that prevents you from using the first-line drugs.

The Step Therapy process utilizes the Alberta Blue Cross prescription drug adjudication system to automatically determine eligibility for coverage of the Step Therapy drug. If the required first-line drug(s) have been claimed within the required time period, you may be eligible for coverage for the

Step Therapy drug. This coverage is provided without having to revisit your doctor to request Special Authorization on your behalf. Subsequent claims for the Step Therapy drug will continue to be covered, as long as there is evidence of continued regular claiming for the product.

In instances where your pharmacist knows you had previous claims for the first-line therapy drug(s) but you have no claims history through the Alberta Blue Cross prescription drug adjudication system, your pharmacist may be able to assist you to obtain coverage through an adjudication intervention, or your doctor may apply for Special Authorization on your behalf.

Alberta Blue Cross Customer Services

Edmonton and area: 780-498-8000

Calgary and area: 403-234-9666

Toll-free: 1-800-661-6995

your guide to the prescription drug Special Authorization process

Special Authorization is a way to provide access to certain medications where there is evidence that a specific subgroup of patients will benefit most from them. These medications are covered only if the criteria of your drug plan are met.

How do I know if my plan uses Special Authorization for certain medications? In general, Alberta government sponsored drug benefit plans, Alberta Blue Cross individual health plans, and some employer-sponsored group benefit plans have Special Authorization in place for specific medications.

How can I find out if my medication requires Special Authorization in order for it to be covered? 1. For Alberta government sponsored drug benefit plans (e.g. Non-Group coverage, Coverage for Seniors, Alberta Employment and Immigration, Alberta Children and Youth Services, and Assured Income for the Severely Handicapped), you have the option to:

a) Check the Internet at: www.health.alberta.ca/AHCIP/drug-benefit-list.html

Click on the Alberta Health and Wellness Drug Benefit List link, then click on Search the Interactive DBL (iDBL).

b) Call Alberta Blue Cross Customer Services using the phone numbers listed on the back of this brochure.

2. For those covered by other Alberta Blue Cross drug plans, please call Alberta Blue Cross Customer Services using the phone numbers listed on the back of this brochure.

What do I need to do to get Special Authorization drug coverage? Please have your doctor complete and submit a Special Authorization request form to Alberta Blue Cross. The information provided by your doctor will be assessed confidentially against clinical criteria established by your plan.

Your doctor may charge a fee for completing the form. This fee is not covered by Alberta Blue Cross or by your drug plan.

How may my doctor or I get a Special Authorization request form?

1. Obtain forms online at www.ab.bluecross.ca/dbl/ forms.html.

Please select the request form for the drug being requested, or use the Drug Special Authorization Request Form if a drug-specific form is not available.

or2. Request a form by calling Alberta

Blue Cross Customer Services using the phone numbers listed on the back of this brochure.

How long does the Special Authorization process take? Once Alberta Blue Cross has received the completed form, the status (approval, pending, or denial) of the request is usually available within three to five business days. If more information is required from your doctor, the assessment may take longer.

How can I check on the status of my Special Authorization request? To check if your request was received or whether a decision has been made, please wait three to five business days after the submission of the request to allow time for its assessment, then call Alberta Blue Cross Customer Services by using the phone numbers listed on the back of this brochure. However, with some medications (antibiotics), the status may be available sooner.

1. If the decision is an approval for Special Authorization coverage, your doctor will be advised. All coverage rules (e.g. co-pays, deductibles, maximums, etc.) of your drug plan will apply to the approved Special Authorization medication.

2. If more information is required in order to assess the request, your doctor will be contacted directly.

3. If the decision is a denial of Special Authorization, Alberta Blue Cross will send a letter directly to you and your doctor.

When is the Special Authorization approval effective, and how long does it last? If Special Authorization coverage is granted, your medication will be covered by your plan only for a specified duration. This pre-determined duration varies depending on the drug and your plan.

You may find out the approval period for your medication by calling Alberta Blue Cross Customer Services using the phone numbers listed on this brochure or by checking with your doctor. Claims for the drug incurred prior to the effective date of the approval are not covered.

If continued treatment is necessary beyond the approved duration, it is the responsibility of you and your doctor to re-apply for Special Authorization coverage prior to the expiration date of the approval.

Your plan covers many prescribed medications as regular benefits. However, other select medications may be eligible for coverage on your plan through the Special Authorization process.

continued on back...