Group insurance
Prior authorization drugs, how does it work?

Some prescription drugs require prior authorization before making a claim.

So, what exactly is prior authorization? What drugs fall into this category? And why? How to request authorization? We answer all your questions.

Questions on everyone’s mind

What is a prior authorization drug?

Also called an exception drug, it’s a drug we need to authorize before it can be reimbursed to you.

Generally speaking, a drug requires prior authorization when:

  • it's expensive
  • treatment is complex or specialized
  • it poses potential health risks
  • there are less expensive yet effective therapeutic alternatives
  • it could be abused or misused

What is prior authorization?

It’s the process we use to determine if a drug can be reimbursed through your insurance plan. First off, your physician fills out a form to confirm that the prescribed drug will be correctly used. Then, we ensure the drug meets our authorization criteria.

These criteria are based on recommendations from various provincial bodies responsible for assessing prescription drugs and follow Health Canada guidelines.

What are the advantages of prior authorization?

It optimizes the cost-effectiveness of expensive drugs by guaranteeing that plan members receive medically appropriate and necessary treatment.

Prior authorization is therefore beneficial for both organizations and insured persons. Not only can it lower the costs in a group insurance plan, it provides insured persons with well-managed care.

Step 1

Check if your drug needs prior authorization

Use our simulation tool in the Client Centre

  • Log in to your Client Centre account and select your group insurance product.
  • In the Shortcuts section, go to Get drug coverage information.
  • This will take you to the Drug Cost Tool. Select an insured person, look for a drug name or identification number, then hit the Search icon.
  • Select the drug you need from the search results.
  • A message will appear letting you know if the drug requires prior authorization. (You can’t miss it!)

  • Open the app and make sure you’re in the Group benefits tab.
  • Go to Eligible prescription drugs.
  • Once in the Drug Cost Tool, select an insured person, look for a drug name or identification number, then hit the Search icon.
  • Select the drug you need from the search results.
  • A message will appear letting you know if the drug requires prior authorization. (You can’t miss it!)

Step 2

Fill out your request for authorization

  1. On our Forms – Prior Authorization Drugs page, search for your drug in our tool.
  2. Select the form that corresponds to your medical condition. If you don’t see it, use the general form.
  3. Fill out your form and sign it. Then ask your physician to complete their part.

Step 3

Send us your request

Your physician may send us the duly completed form, though you can also send it yourself by fax, mail or online.

Fax 1 855 453-3942

Mailing address

CP 11051, succ. Sainte-Foy
Québec QC  G1V 0K1

Step 4

Wait for our answer

Our team of pharmaceutical experts will review your request within five working days after receiving your form. An answer to your request will be provided on the statement for this claim or in a letter, depending on the complexity of your file.

1. On your claim statement

Do you have a Client Centre account?

You’ll receive an email when your statement or letter is posted. Or you’ll receive your document in the mail within 10 working days following the receipt of your form.

  • Log in to your Client Centre account and select your insurance product.
  • Under Recent claims, go to All statements.
  • Select your claim from the list. It should have a Denied status and $0.00 as the reimbursement amount.
  • Go to View Statement.
  • The answer to your request for authorization will be included in the Explanation of benefits section.

  • Open the app and make sure you’re in the Group benefits tab.
  • Go to Claims history.
  • Select your claim from the list. It should have a Denied status and $0.00 as the reimbursement amount.
  • Go to View Statement.
  • The answer to your request for authorization will be included in the Explanation of benefits section.

2. In a letter

An answer will be sent in a letter in the following situations: 

  • If there was a request to review and it was denied.
  • We have to ask your physician for additional information before making our decision.
  • The dosage requested by your physician doesn’t match the dosage recommended by Health Canada.

You’ll receive it in the mail within 10 working days following the receipt of your form.

If, after 10 working days, you still haven’t received an answer, call us at 1 877 651-8080 to follow up on your request.

Step 5

Complete the process

First things first: check when your authorization expires. We always include this date in our answer. The accepted dose and frequency of use may also be specified.

See your physician before this date to fill out a new prior authorization drug form and renew your prescription.

Authorizations generally last from 6 months up to 4 years. This timeline can vary depending on your condition and the drug.

After analyzing each file, and in keeping with our policies, we sometimes refuse to reimburse a drug. This can happen when a medical condition doesn’t meet the defined criteria to authorize a drug.

Criteria are based on medical recommendations and expert advice to guarantee effective care adapted to each person.

If your request is denied, discuss other potential therapeutic options with your physician. You can request a review if new medical information becomes available.