Applying for specialty drug coverage – what you need to know

Principals/Vice-Principals (P/VP)

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Applying for specialty drug coverage – what you need to know

If your doctor prescribes a specialty drug, you may need approval, or “prior authorization”, before the ONE-T Benefits Plan will reimburse the cost. This process helps ensure you receive the right treatment, at the right dose, at the right time.

Did you know?

When a drug claim is approved, it is paid from the ONE-T Benefits Plan fund. Since this fund supports all Plan Members and their covered dependents, it’s important that resources are used well – ensuring every dollar is spent fairly and responsibly.

What is prior authorization?

Prior authorization is a review process for specialty drugs (those that cost $5,000 or more per year and other categories, such as anti-obesity medications). Specialty drugs are used to treat certain conditions; here are a few examples: rheumatoid arthritis, Crohn’s disease, multiple sclerosis, obesity, and psoriasis.

Before coverage is approved, the process confirms that:

The drug is the most appropriate treatment for your condition and meets plan eligibility criteria
The dose and duration are appropriate for you
The therapy aligns with current clinical guidelines

Our service partner, Cubic Health, will work collaboratively with your physician and/or pharmacist throughout the approval process.

Did you know?

For many complex diseases, there are often multiple treatment options available – including some that are equally (or more) effective, safer, and less costly.

Why it matters

Although only a small number of Plan Members need drugs that require prior authorization, the process plays a big role in:

Ensuring safe, effective, evidence-based care
Using Plan resources wisely

In short, prior authorization helps you and your eligible dependents get the best possible treatment within the parameters of the Plan, backed by expert review and personalized support.

How it works

Cubic Health has been helping Plan Members access specialty drugs for years through its FACET program. Each request is confidentially reviewed by an independent clinical pharmacist using transparent, evidence-based clinical criteria.

Most decisions are made within 24-48 hours, helping ensure you can begin treatment without unnecessary delays.

You’ll also receive guidance to help you:

Understand what your doctor needs to submit
Navigate the steps in the process
Review results and plan next steps

This support helps make the experience smooth and transparent.

Note: if your request is not approved, you can still choose to take that drug; however, the cost will not be covered by the ONE-T Benefits Plan.

12% of respondents from our recent Plan Member Survey said they’ve connected with Cubic Health in the past 12 months, either to apply for approval or renew their approval for a specialty drug.

Tips for an easy process

1. Check early: Once you’re prescribed a new drug, check here to see if it needs prior authorization. If so, apply right away.

2. Stay connected: Watch for emails or calls from FACET, your doctor, or your pharmacist to keep your application moving.

3. Ask for help: FACET program coordinators are available if you have questions or need guidance.

For more details on Prior Authorization, visit ONE-T.ca to view the Prior Authorization page or refer to your Plan booklet.

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