The Trustees are committed to effectively managing our drug plan while ensuring members and their families receive the care they need. Since 2005, the IBEW Local 353 Benefits Plan has required Pre-Approval (also known as Prior Authorization or PA) for many specialty prescription drugs before they can be paid for under the Plan. PA determines if a medication can be reimbursed under the plan given the complexity of medical conditions treated using specialty drugs, and the need to ensure a consistent and transparent set of clinical criteria across the 200 different diagnoses that are seen through the PA process every year.
Currently the Plan uses the FACET Prior Authorization Program (FACET) to assess PA requests for claim approval and reimbursement. FACET is an independent, third-party program that helps to ensure that high-cost medications are used appropriately, safely, and in accordance with the latest clinical evidence from Health Canada and Canada’s Drug Agency. PA helps protect plan members by ensuring that treatment decisions are based on sound medical evidence and it also protects the long-term sustainability of the Benefits Plan. A PA medication requires your doctor to complete a PA form and submit it directly to FACET for review.
It’s important to note that the PA by FACET is not questioning an underlying diagnosis from a doctor. The PA process simply assesses what the Plan will reimburse. In cases where the FACET PA indicates a medication can’t be reimbursed by the Plan, a detailed explanation citing the most up-to-date clinical evidence is sent to both the member and their prescribing doctor.
Most approvals under FACET are valid for a maximum of one year before the PA request needs to be renewed. A common reason for this is that many complex, specialty therapies are biologically based and their impact can lessen over time as the body develops antibodies to the medication. Sometimes a member may need to move to another specialty therapy if during the renewal process it is clear the medication is losing its effectiveness.
Understanding Drug Types: What’s the Difference Between Biologics, Biosimilars, and Generics?
You may have heard terms like biologics, biosimilars, or generics used when talking about prescription medications. These terms refer to different types of drugs, and the types of drug can affect how our Benefit Plan covers them. Here’s a simple breakdown:
Generic Drugs: Chemically Identical, Lower Cost
Generic drugs are copies of brand-name medications and contain the same active ingredients, work the same way in the body, and are held to the same quality and safety standards as brand-name drugs. Generic drugs are less expensive than the brand name drug, and the Benefit Plan will usually only cover the cost of the lowest-priced equivalent generic, unless your doctor clearly indicates that the brand-name version is medically necessary (for example by writing “no substitution” on your prescription). Most generic drugs don’t require prior authorization (PA). However, some generic medications, especially those used for rare or complex conditions, are considered specialty drugs due to their high cost. If the drug requires a PA your doctor or pharmacist will let you know.
Biologics: Complex, Specialized Medications
Biologic drugs are made from living cells, not chemicals. They are used to treat complex conditions such as autoimmune diseases or cancer. Because of their complexity, biologics are often more expensive and may have prior authorization (PA) requirements to make sure they are being used safely and appropriately.
Biosimilars: Safe, Effective Alternatives to Biologics
Biosimilars are near-identical versions of biologic drugs whose patents have expired. They are not generic copies (since biologics are too complex to replicate exactly), but they are highly similar in terms of safety, quality, and effectiveness. Health Canada reviews biosimilars using the same strict standards as all prescription drugs. In many cases biosimilars cost up to 50% less than their originator biologics. Given their clinical complexity and relatively high cost, most biosimilars, whether for new users or those switching from an originator biologic, will require a prior authorization (PA) application. This helps ensure the medication is used appropriately and that plan resources are managed responsibly. Most biosimilar drugs are manufactured by brand name drug companies. They are not considered generic drugs.
Plan Policy: Switching to Biosimilars
To help keep the IBEW Local 353 Benefits Plan affordable and sustainable for all members the Trustees adopted a biosimilar transition policy which means that if a member of the Plan is taking a biologic drug and a biosimilar becomes available, they may be required to switch to the biosimilar to maintain coverage. This approach aligns with what every provincial plan and most private plans are doing across Canada, including the Ontario Drug Program. Canada Life will notify you if you are required to switch to a biosimilar drug. If that happens and you believe the biosimilar is not suitable, talk to your doctor. They can complete and submit a form to the FACET program explaining why the biosimilar cannot be tolerated.
Important: the “no substitution” rule that applies to generics does not apply to biosimilars. Approval through the FACET program is required for continued coverage of the originator biologic.
Remember: Specialty prescription drugs PA applications should not be sent to Canada Life.
All PA requests need to be sent to the FACET Program directly. Email the completed form to claims@facetprogram.ca or fax to 1-844-446-1575. You can also call them at 1-844-492-9105.
You can learn more by visiting https://facetprogram.ca and reading the FAQ here.
Questions? We’re here to help! You can email us at members@teibas.com or call us at 416-637-6789 (toll-free 1-800-267-0602) for assistance during our regular office hours (Monday to Friday 7:30 a.m. – 4:30 p.m.).