Understanding prior authorization

Some medications require prior authorization due to their cost or specific usage guidelines.

Why do certain medications require prior authorization?

To confirm eligibility for coverage, we establish medical criteria that must be met before approval is granted. This process helps confirm that the medication is being used in alignment with recognized treatment standards.

How to find out if your medication requires prior authorization?

1. From the Navigation Bar, select Coverage.

2. Select Check Coverage.

3. Select Drug (Prescription).

4. Select a Plan Member and enter the Drug name or DIN.

5. Select Search. A table will appear that includes information about the eligibility for your prescription and you can select View Details to download the authorization form.

If your prescription requires prior authorization, you can choose to:

• Submit the authorization form to determine whether your medication is eligible for coverage under your plan. To avoid delays, please complete this step early. Reviews may take time and could affect when you receive your medication.

• Purchase the medication at your own expense and submit a claim after. This allows you to receive your medication immediately. However, prior authorization is still required, and if your request is denied, you will not be reimbursed for the out-of-pocket cost.

Apply for prior authorization

1. Get the Prescription Drug Special Authorization Form and/or the Eligibility Criteria Sheet for the prescribed medication. You can do this in one of the following ways:

   • Download the forms from our online platform. Visit Download Authorization Forms for more information.

   • Contact us to request the Forms by email ([e-mail]) or by phone [phone]).

   • Ask your pharmacist to print the forms from the Provider Connect website. Your pharmacist can give you the forms or fax them to your physician.

2. Ask your physician to assess your eligibility by reviewing the Eligibility Criteria Sheet.

   • If you are eligible, complete the Prescription Drug Special Authorization Request form with your physician.

   • If you are ineligible, ask your physician about alternative options or pay for your prescription at your own expense.

3. Submit the Prescription Drug Special Authorization Form to us using one of the following methods:

   • By Email: Scan the document and email to [e-mail]

   • By Mail: GreenShield Attn: Drug Special Authorization, P.O. Box 1606, Windsor, ON N9A 6W1

   • By Fax: [phone]

Check the status of your request

1. From the navigation bar, select Coverage.

2. Select Medication Prior Authorization.

We will make every effort to process your request quickly and avoid delays. You will receive a response by regular mail. You can also check the status of your request by calling our Customer Service Centre at 1-604-689-7184.

If your request is approved, the medication will be paid for by your drug plan, and you can fill your prescription as usual by presenting your Plan Member ID card. For certain prior authorization drugs, we only approve coverage for a specific period of time. Should you need the medication beyond the initial approval period, further information will be required to be approved for an additional period.

If your request is denied, the medication will not be paid for by your drug plan. You can choose to pay for the medication yourself, or ask your physician about alternative options.