Section 18 of The Pharmaceutical Services Act entitled ‘Special Authorization Review’ outlines the Special Authorization Review and Exceptional Review Process (formerly known as Non-funded Process)
“18. (1) A prescriber may, on behalf of a beneficiary, request a drug for which special authorization is required under the program.
(2) A request shall be considered in accordance with criteria developed by
(a) the National Common Drug Review or the Joint Atlantic Common Drug Review or their successor organizations;
(a.1) the pan-Canadian Oncology Drug Review; or
(b) other committees or processes as determined by the minister and adopted by the minister.
(3) If a request for special authorization has been declined based on the criteria referred to in subsection (2), a prescriber may request an internal review of the matter.
(4) If, after consideration in an internal review the request for special authorization is again denied, a prescriber may apply to the medical practitioner designated by the minister for a review of the decision and the decision of that medical practitioner with respect to the special authorization is final.”
Subsection (4) above provides the authority for the Exceptional Review Process.
Special Authorization Process
It is the Department’s responsibility to ensure that we spend our public funds where scientific evidence supports significant health outcomes. The NLPDP uses evidence based decision-making processes to consider coverage of drugs under the program. Therefore, all drugs are reviewed by one of the committees noted above. These committees make recommendations on whether a drug should be listed under a public drug program with or without restrictions meaning if a beneficiary must meet certain criteria before the drug can be considered.
Coverage of special authorization drugs will be assessed:
- according to defined criteria;
- upon receipt of the required clinical information from a health care provider involved in the patient’s care; and
- subject to a drug review by staff of the Pharmaceutical Services Division.
Special authorization request forms have been prepared at the request of healthcare providers that may be used to facilitate the special authorization assessment process. Requests can be faxed or mailed and are assessed in the order received. The use of the form, while not mandatory, is encouraged to expedite the assessment process. Special Authorization Request Forms can be found at https://www.health.gov.nl.ca/health/forms/index.html#4.
If a prescriber wishes his/her patient to receive a drug that is not listed as an open benefit on the Coverage Status Table, but is listed as requiring Special Authorization, the Health Care Provider may contact the Program on behalf of his/her patient with a request for Special Authorization documenting medical need. The Beneficiary and the requesting Prescriber will receive written notification of the Program’s decision.
Drugs listed in this category are available to beneficiaries who meet certain defined criteria. Request must be made by a health care professional on behalf of the beneficiary.