Lacking special authority

"Anything else I can do for you, Bob?"

"Yeah doc, the pharmacist said you can get my medications paid for."

"But Bob, you don't qualify for Special Authority coverage."

"What do you mean, doc? My pharmacist said all I had to do was talk to you and I could save money. What's the matter--you keeping it for yourself?"

I frequently have conversations like this one in my office. As I age I have less and less tolerance for the Special Authority program. From the outset I was a little concerned that this program would lead to more unpaid work.

Initially, there were five classes of medications included in the Reference Drug Program--H2-blockers, NSAIDs, nitrates, ACE inhibitors, and calcium channel blockers. Pharmacare would provide full coverage for the drug(s) they deemed most medically effective and cost effective in each category.

The program then expanded to include the Low Cost Alternative Program and Limited Coverage Drugs. Essentially, Pharmacare will pay for the generic form of a medication under the Low Cost Alternative Program and not pay for medications under the Limited Coverage program as these are medications not generally accepted as first-line treatment and for which cheaper alternative medications exist.

Lastly, the Alzheimer's Drug Therapy Initiative was born, which stipulates the criteria for Pharmacare coverage of cholinesterase inhibitors for dementia.

Initially, there was one form for medical practitioners to fill out requesting Special Authority coverage for a medication falling outside of the referenced category. The forms have proliferated as programs have expanded. The criteria for coverage have also become more complex, often including multiple situations such as, "must have tried all medications past and present with at least one from each continent starting 2 years before they were born until death with a dose range from a microgram to a kilogram," followed by the instructions, "please list all of the medications tried in alphabetical order, spelled backwards with the corresponding number of days tried documented by their cube root."

Specialists often have prescribing exemptions for certain medications so no Special Authority is required. However, the rest of us are stuck filling out these ever-more-involved forms with no remuneration. We are unable to charge for completion of these forms, which is somewhat ironic considering their completion saves the patient a significant amount of money. Pharmacare has a number you can call to verbally apply for Special Authority, but again this requires a time investment. Not that money is our major motivation, but considering this process also saves the government money, why did we get nominated to provide this free service?

My biggest complaint is that patients are directed to my office to request this special coverage without being advised of the entire process. This sets up an adversarial situation where their advocate (me) has to tell them they don't qualify.

Perhaps pharmacies could add the Special Authority criteria to the medication information printouts they provide to patients, or maybe Pharmacare could send this information directly to patients. This would allow patients to be better prepared and informed prior to meeting with their physician. Meanwhile, I will continue to field these questions about medication coverage, which leaves me feeling less than special and without authority.

--DRR

David R. Richardson, MD. Lacking special authority. BCMJ, Vol. 56, No. 7, September, 2014, Page(s) 313 - Editorials.



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