In response to a demand for catastrophic drug coverage, UBC has developed guidelines under which a claims adjudicator is appointed to examine cases and to assist active status faculty and staff members facing financial hardship as a result of requiring expensive drug therapy for themselves or their eligible dependents for catastrophic illnesses.
This policy also seeks to ensure safe, appropriate, and effective utilization of specialty drug therapies that is supported by Health Canada and ongoing medical research.
A third-party adjudicator will review the claims based on criteria listed in the Catastrophic Drug Claim Appeal Policy document. All decisions by the claims adjudicator are final.
University of British Columbia Catastrophic Drug Claim Appeal Policy
This policy is effective January 1, 2010 for a ten-year period ending on December 31, 2020. The policy is subject to review, and may change during this period.
The implementation of an equitable, objective, and consistent process to assist active status faculty and staff members facing financial hardship as a result of requiring expensive drug therapy for themselves or their eligible dependents for catastrophic illnesses. This policy also seeks to ensure safe, appropriate, and effective utilization of specialty drug therapies that is supported by Health Canada and ongoing medical research.
Criteria for Drug Appeal Process
- An appeal will only be considered once all options have been pursued through other resources (e.g., Fair Pharma Care Special Authority, BC Cancer Agency compassionate grounds).
- The program is open to active status faculty and staff members who are enrolled in the University’s extended health plan, and their eligible dependents as defined under the plan.
- No appeals will be considered for drugs that are specifically excluded under the University’s extended health plan, or that are for strictly aesthetic purposes.
- An appeal under this policy must be made within 6 months of the drug being declined under the University’s extended health plan.
- Approved claims will be subject to the drug coinsurance level under the University’s extended health plan.
- There is a lifetime appeal reimbursement maximum of $50,000 per person under this policy.
- Appeals will only be considered if the expenses for the drug therapy under appeal exceed 2% of the faculty/staff member’s annual family income. The faculty/staff member will be required to complete a declaration of family income. No appeal will be considered for claims that have an average annual cost below $1,000.
- Appeal adjudication will be based on balanced consideration of evidence of the effectiveness of a given drug therapy to treat a specific condition as reviewed by a Canadian Health Technology Assessment (HTA) body (i.e. Canadian Agency for Drugs and Technologies in Health), or if unavailable, similar and relevant HTA bodies in other jurisdictions, a drug’s place in therapy, and the availability of alternative therapies.
- Generally, in order to be considered for coverage, a drug must have an approved indication for use for the given disease state or condition in question with Health Canada, the FDA, or similar European agency, or the manufacturer must have filed a formal application to expand the approved list of indications for the disease state in question. A claim may still be considered if this is not the case, but only if all indicated drugs for the condition have been tried without success, and the drug has the potential for success, based on sufficient medical evidence (i.e. randomized controlled trial evidence).
- If the drug under appeal is considered a second-, third-, or fourth-line agent for the treatment of a given condition according to its indications and/or clinical practice guidelines, explanation(s) of treatment failures with other agents may be required.
- Any drug being considered for appeal must be prescribed by a specialist for the disease state/condition in question.
- Plan members must share relevant medical and drug information with the third party provider responsible for adjudicating the appeal on behalf of UBC, in order to allow for verification of appeals criteria. This will include details of diagnosis, past treatments and may require contact between the specialist care provider and the third party adjudicator. All medical information received by the third party adjudicator will be kept confidential. Request for information from the third party adjudicator should be complied with promptly in order to expedite the review process.
- Clinical decisions will be made within five (5) business days from the time that all necessary information is received on a given case.
- The third party adjudicator may approve appeals with specific clinical conditions (i.e. specified duration of therapy, specified number of approved doses, required documentation of efficacy) if deemed appropriate.
- The decision of the claims adjudicator is final. In cases where the diagnosis or treatment protocol have changed substantially (i.e. disease progression or failure of alternative therapies), a new appeal application may be requested and is subject to the overall lifetime appeal reimbursement maximum stated in this policy.