Beginning on January 1, 2020, the ETFO Employee Life and Health Trust (ELHT) and OTIP launched the new OTIP Drug Prior Authorization Program for plan members.
This new program is being used for all drug prescriptions requiring prior authorization.
Members who were on a prior authorized drug prior to January 1, 2020, are not affected by this change.
Most eligible prescription drugs covered by the ETFO ELHT Benefits Plan are authorized at the pharmacy when you present your benefits card. However, some medications that have multiple uses and/or are considered specialty drugs require prior authorization before they can be covered.
Specialty drugs are used to treat complex, chronic or life-threatening medical conditions such as: rheumatoid arthritis, Crohn’s disease, multiple sclerosis (MS), pulmonary arterial hypertension (PAH), cancer, osteoporosis and hepatitis C.
Due to their cost, and in some cases, complexity of treatment, most specialty drugs require prior authorization to confirm that they will be covered by the plan.
About the new prior authorization program
The new OTIP Drug Prior Authorization Program uses an independent, clinical pharmacist team called FACET.
The FACET team communicates directly with your doctor to ensure that you and your eligible dependants receive the most appropriate, safe and effective treatment for the condition. This program will ensure that all specialty drug prescription decisions are objective and based on the most up-to-date, evidence-based information available.
How to access the OTIP Drug Prior Authorization Program
If you or a family member covered under the plan need to seek approval for a specialty drug under the ETFO ELHT Benefits Plan, simply follow the steps below:
The OTIP Drug Prior Authorization Program website can also be accessed directly by both members and physicians at pa.otip.com.
If you are unsure about whether a medication requires prior authorization, use the Drug Lookup Tool in My Claims to search for the name of your medication. The Drug Lookup Tool will provide details on whether the medication is immediately covered by your plan or if it requires prior authorization.
If all of the information required by the FACET team is provided, a decision about the coverage of a drug requiring prior authorization will be made within two business days. Where additional information may be required, a decision will be made within five business days 99% of the time.
Once the prior authorization decision has been made, you and your physician will be notified by the FACET team and provided with the specific rationale used to make the final decision.
More information about the program can be found in the FAQ section of the prior authorization website.
If you have any questions about the new drug prior authorization program or specialty drugs, please call OTIP Benefits Services at 1-866-783-6847.