Prior Authorization for High Cost Drugs

Sunday, March 26, 2017
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Prior Authorization for High Cost Drugs

High cost specialty drugs are used by a small number of members but the cost to health plans is significant and growing. To help manage these costs, and to ensure the sustainability of your health plans, we implemented a Prior Authorization Program for High Cost Drugs.

This means we will require prior authorization forms to be submitted and approved before we can reimburse prescriptions costs.

What drugs are part of the program?

These classes of drugs will be part of this program:

  1. High cholesterol biologics (PCSK9 Inhibitors) – Repatha™, Praluent™
  2. Hepatitis C – Daklinza™, Epclusa™, Harvoni™, Sovaldi™, Sunvepra™, Zepatier™
  3. Idiopathic Pulmonary Fibrosis - Ofev™, Esbriet™
  4. Botox™ and Xeomin™
  5. Severe Asthma - Cinqair™, Nucala™
  6. Pulmonary Arterial Hypertension - Adcirca™

What are the benefits of this program?

  1. Helps prevent increases in insurance premiums by protecting your benefit plan from escalating drug costs
  2. Ensures these drugs are taken appropriately at the right place in therapy and have been prescribed according to Health Canada recommendations.
  3. May save you some out-of-pocket costs for expensive drugs.

How do I submit a prior authorization application?

  1. You will likely be notified by your pharmacist or a drug manufacturer’s Patient Assistance Program that your medication requires prior authorization.
  2. Download the corresponding prior authorization form for your type of drug. The form needs to be completed by your physician.
  3. Fax the completed form to 604 419-2689 (toll-free 1 888 419-2689) or mail to:
    Attn: Pharmacy Services
    Pacific Blue Cross
    PO Box 7000
    Vancouver, BC V6B 4E1
  4. We will review the form and make a decision within 5 business days in most cases. You will then be informed of our decision. You can also view approvals in CARESnet in Claims » Pre-Authorizations.

The drug manufacturer’s Patient Assistance Program and pharmacies in our Preferred Pharmacy Network can assist you with this process.



Prior Authorization Forms for High Cost Drugs

These forms need to be completed by your physician.

High cholesterol biologics (PCSK9 Inhibitors)



Idiopathic Pulmonary Fibrosis


Botox™ and Xeomin™


Severe Asthma


Pulmonary Arterial Hypertension


Prior Authorization Drugs program overview



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