FACET Prior Authorization Drug Program

The UBC Extended Health Plan provides you and your eligible dependents with comprehensive coverage for medical services, supplies and prescription drugs.

Effective May 6, 2018, specialty drugs that are used to treat specific health conditions and that cost more than $5,000 per person, per calendar year will require pre-approval (“Prior Authorization”). This means that if your physician prescribes such a specialty drug for you or your covered dependents, you and your physician must submit evidence that supports the need for the drug in order to obtain coverage for it under the extended health benefit plan.

If you or your covered dependents were reimbursed for a specialty drug under UBC’s extended health plan in the 12 months prior to the effective date of the program (May 6, 2018), you will be automatically grand-parented and will not be required to apply for prior authorization (PA) for that drug. Read on for more details.

Specific Health Conditions that Require Pre-approval/Prior Authorization

Certain drugs that are used to treat the following health conditions, and that cost over $5,000 per calendar year, per person require prior authorization:

  • Asthma
  • Cancer
  • Crohn’s Disease/Ulcerative Colitis
  • Hepatitis C
  • Hypercholesterolemia
  • Multiple Sclerosis
  • Psoriasis
  • Psoriatic Arthritis
  • Rheumatoid Arthritis

About Prior Authorization (PA)

Prior authorization is used in many organizations’ extended health and dental benefit plans for high-cost medical services, supplies, procedures and prescription drugs. This approach ensures that specialty drugs are reimbursed when most needed so that extended health benefit plans remain stable and sustainable.

At UBC, our new PA drug program is referred to as FACET and is administered by an independent, third-party organization called Cubic Health. FACET offers the following:

  • Prescription drug experts (licensed pharmacists) who make evidence-based decisions
  • Provides expert support in navigating related issues and collaborates with you and your physician to ensure appropriate drug and dose regiments for effective treatment
  • Coordination of coverage with the BC Fair PharmaCare Plan and other provincial drug plans, while continuing to provide choices in prescription drug treatment

Additional Information

  • Through FACET, Cubic Health uses up-to-date, evidence-based clinical criteria for a given health condition to determine approval of a specific drug. Each claim is reviewed by a licensed pharmacist at Cubic Health, and a decision is typically rendered within three business days of the receipt of required information.
  • Approved drugs under FACET’s PA program will have a maximum approval period of one year, and will be reimbursed by Sun Life based on the prescription drug coverage of your extended health benefit plan. In order to be considered for an approval extension, a renewal form must be completed prior to the end of the approved authorization period.
  • If a drug is not approved, you and your physician will be contacted directly to discuss alternatives. The extended health benefit plan will continue to provide choices for your treatment in consultation with your doctor.
  • If you or your covered dependents were reimbursed for a PA drug under UBC’s extended health plan in the 12 months prior to the effective date of the program (May 6, 2018), you will automatically be grand-parented, and will not be required to apply for PA for that drug. However, if there is a requirement to change an existing prior drug, or to add another PA drug to your medication regimen, you will be required to apply for prior authorization for that drug.

Process for Obtaining Pre-approval for Coverage of a Specific Drug

1. Starting May 6, 2018, you can find out which prescription drugs require prior authorization by logging in to Sun Life’s website at www.mysunlife.ca (currently not available on Sun Life’s mobile app).

Once logged in, go to coverage information, medical – drug coverage, drug look up and search by drug name or DIN (drug identification number).

If your prescription drug requires prior authorization, you will receive a message indicating “to be considered for coverage for this drug, have your doctor complete the appropriate form”.  You will be directed to the FACET Prior Authorization Drug Program webpage to complete the form (go to Step 2).

If you do not receive this message, prior authorization is not required at this time and no further action is required by you.

2. Go to the FACET webpage to find the Prior Authorization Request Form that matches your health condition.

3. Ensure that you and your physician complete the form – this can be completed through the “fillable” form.

4. Submit the form and supporting clinical information to Cubic Health via one of the following ways:

Note: Medical information is submitted directly to Cubic Health, and is not shared with UBC.

5. Allow three business days for review once all necessary information has been received by Cubic Health.

6. If your drug is approved, Cubic Health will notify Sun Life to cover the drug for a one-year period.

7. If the drug you were prescribed cannot be approved, your physician will be contacted by Cubic Health directly to discuss alternatives.

8. Cubic Health will send both you and your physician the decision in writing.

Frequently Asked Questions (FAQs)

1. Why is UBC using prior authorization (PA)?

Prior authorization is used in many organizations’ extended health and dental benefit plans for high-cost medical services, supplies, procedures and prescription drugs. This approach ensures that specialty drugs are reimbursed when most needed so that extended health benefit plans remain stable and sustainable.

At UBC, our PA drug program is referred to as FACET and is administered by an independent, third-party organization called Cubic Health. FACET offers the following:

  • Prescription drug experts (licensed pharmacists) who make evidence-based decisions
  • Provides expert support in navigating related issues and collaborates with you and your physician to ensure appropriate drug and dose regiments for effective treatment
  • Coordination of coverage with the BC Fair PharmaCare Plan and other provincial drug plans, while continuing to provide choices in prescription drug treatment

2. What if I’m currently using a drug that is now part of the PA program?

If you or your covered dependents were reimbursed for a PA drug under UBC’s extended health plan in the 12 months prior to the effective date of the program (May 6, 2018), you will automatically be grand-parented, and will not be required to apply for prior authorization.  However, if there is a requirement to change an existing PA drug, or add another PA drug to your medication regimen, you will be required to apply for prior authorization for that drug.

3. What is a specialty drug under the PA drug program?

A specialty drug is defined as a drug product typically prescribed by a specialist in a given therapeutic area, and that has a cost of $5,000 or more per calendar year, per person. Specialty drugs are expensive because they include medications that require special manufacturing, distribution, and administrative procedures.

4. What are the health conditions for which specialty drugs require pre-approval?

The FACET prior authorization drug program is based on specific health conditions, and each has its own form. Certain drugs that are used to treat the following health conditions, and that are over $5,000 per calendar year, per person, require prior authorization:

  • Asthma
  • Cancer
  • Crohn’s Disease/Ulcerative Colitis
  • Hepatitis C
  • Hypercholesterolemia
  • Multiple Sclerosis
  • Psoriasis
  • Psoriatic Arthritis
  • Rheumatoid Arthritis

If you are prescribed a PA drug that treats a condition not listed above, please complete the General Request Form with your physician, including any relevant medical and medication history, as well as lab results.

5. What if my physician charges a fee to complete the prior authorization request forms?

Not all physicians charge a fee to complete forms, however if yours does, this cost is not covered by the UBC Extended Health Plan.  If you are eligible for the Health Spending Account (HSA), you can apply these expenses to the HSA and/or alternatively, speak to your physician in advance about prior authorization and have the forms completed during the visit, if required.

6. If I have a health condition that is included in the list of drugs under the PA program, but I am not taking a PA drug, do I have to obtain prior authorization for other drugs that I am taking?

Prior authorization is not required for drugs that cost less than $5,000 per calendar year, per person.  However, PA may be required for specific drug products that cost less than $5,000 per year where there are safety concerns.

7. How do I or my covered dependent get reimbursed for approved PA drugs?

Once authorization is obtained and Cubic Health has notified Sun Life, you can obtain coverage by using your pay-direct drug card at your pharmacy, or by submitting a Sun Life (www.mysunlife.ca) claim if you’ve paid your pharmacy for your prescription up front.

8. How long is the authorization for the PA drug valid for?

Prior authorization approvals are valid for one year.

9. What do I or my dependent plan member need to do to renew a prior authorization?

To renew a PA drug, please have your physician complete parts 6 and 10 of the FACET Prior Authorization Form prior to the end of the approved authorization period. Renewals are based on the demonstrated safety and clinical effectiveness of the drug, as well as your adherence to the drug therapy.

10. What criteria will be used by Cubic Health to render a decision to approve or decline a claim?

Cubic Health relies on the most recent evidence-based criteria developed from Canadian clinical practice guidelines, Canadian drug monographs, and supporting information from the Canadian Agency for Drugs and Technologies in Health drug reports to render clinical decisions.

Cubic Health addresses two key questions during their review:  does the covered individual qualify for any specialty drug for a given condition, and if so, what is the most appropriate (evidence-supported), cost-effective initial drug and dosage regimen that is eligible under the plan?

11. Can I or my physician appeal a FACET decision?

In the event that a drug is not approved, the Cubic Health licensed pharmacist will focus on explaining the evidence-based rationale to you and your physician, and will identify other options that you can consider.

It is possible for you and your physician to appeal a FACET decision provided one or more of the following criteria are met:

  • The underlying health state has changed materially since the initial FACET decision, warranting a review of the claim;
  • There are documented and justifiable clinical reasons why specified alternatives are not options for a given patient in a given case; and/or
  • There has been a material change to the underlying primary evidence base, warranting a review.

Appeals are not considered for products that are specifically excluded from the extended health benefits plan.

12. What is the process to appeal a FACET decision?

To appeal a FACET decision, please have your physician submit in writing to Cubic Health the rationale explaining why the therapeutic alternative(s) identified by the FACET program are not appropriate for your case, and/or why the declined medication is the most appropriate treatment option, along with any relevant supporting documentation (e.g. test results, consult notes, etc.) Appeals can be faxed to 1-844-446-1575 or emailed to UBC@facetprogram.ca.

13. What happens if I submit a specialty drug claim to Sun Life on or after May 6, 2018 without approval from Cubic Health under the FACET PA Program?

If the drug is included in the FACET PA program and you have not been grand-parented, the claim will be declined and you will receive a message from Sun Life stating, “This expense requires prior authorization.  You can obtain authorization from Cubic Health.”  The message will contain a link to Cubic Health’s FACET website, as well as Cubic Health’s contact information.

14. Will the list of prior authorization drugs change?

Yes. Cubic Health actively monitors new drugs receiving Health Canada approval. As new specialty drugs come to market, they will be added to the list of prior authorization drugs. Similarly, if a drug is discontinued, it will be removed from the list.

15. Is any of my information shared with UBC?

No.  Under no circumstances does Cubic Health share details of any FACET prior authorization application with UBC.


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