Clinical Experts, Responsible Care

OTIP has partnered with Cubic Health’s Facet Program to provide members with safe, effective and appropriate specialty drug therapy. Our mission is to provide you with objective, evidence-based decision-making by a clinical pharmacist team, while ensuring the responsible use of plan resources for a sustainable benefits plan for years to come.

Find my patient's form FAQ

Clinical Philosophy

Fairness

Given the complexity of both the underlying disease states and specialty therapies within FACET, and to ensure transparency, fairness and consistency in PA claims assessment, FACET employs an evidence-based approach to reviewing every claim. The clinical rationale for each decision made using the latest clinical evidence is shared with both the patient and their physician/specialist to ensure there is complete understanding with respect to how a decision was rendered.

Independence

FACET leverages the following clinical evidence to render fair, consistent, and transparent decisions:

Updated Clinical Practice Guidelines specific to a given disease state
Independent Health Technology Assessments (HTA) agency evaluations and recommendations that measure clinical and cost-effectiveness of individual products from sources such as Canadian Agency for Drugs & Technologies in Health (CADTH), National Institute for Health and Clinical Excellence (NICE), Institut national d’excellence en santé et en services sociaux (INESSS), etc.
Review of new and existing therapies on the market (i.e. approved indications, availability, pricing, comparative studies, etc.)
Review of clinical trial information published in primary medical literature

The Process

Step 1

Find your patient’s Prior Authorization Form

Step 2

Complete the form

Step 3

Submit the form to FACET by e-mail or fax for review

Step 4

A clinical decision will be rendered and communicated to you and the patient

Over

600,000

members covered by the Facet Program in across Canada

99%

of claims decided in less than a week

Over

40%

of FACET submissions require intervention to optimize therapy

Frequently Asked Questions

What is the FACET program?

OTIP has partnered with Cubic Health’s FACET program to provide members with safe, effective and appropriate specialty drug therapy. Our mission is to provide you with objective, evidence-based decision-making by a clinical pharmacist team, while ensuring the responsible use of plan resources for a sustainable benefits plan for years to come. All prior authorization that currently takes place in Canada is drug-based, meaning that a doctor must fill out a specific form for a specific drug they are looking to prescribe. FACET is different – the focus is on you and your health condition, not just the drug. We need appropriate information to determine which therapy is the most appropriate for you based on your existing disease state and past drug therapy. The only way to ensure plan resources are being used appropriately is to examine your disease state characteristics and previous drug therapy in detail. That requires a different approach to what is available today.

How does FACET protect my personal health information?

What criteria does FACET use to reach a decision?

How can I ensure that my claim is processed as quickly as possible?

The best way to do this is to ensure that the form is completed as thoroughly and accurately as possible. Some helpful reminders include:

Be sure to read and sign the consent page
Include your email address for faster replies from our pharmacy team and to receive renewal reminders if you are approved for a long-term/chronic medication
Ensure that your doctor fills in all required clinical information as indicated on the form and attach any relevant supporting documentation (imaging results, blood counts, clinical notes, etc.)
If you reside in a pharmacare province (British Columbia, Saskatchewan, Manitoba), please ensure to include the decision letter from the provincial program as well.

My doctor charges a fee for filling out the prior authorization form, will I be reimbursed for that fee?

My patient support program coordinator offered to start me on this medication for the time being. Will this increase my chances of being approved?

What are the possible program outcomes?

There are three possible outcomes within the FACET program:

Claim is approved as submitted
Claim is conditionally approved – A decision was made that specialty therapy is approved for you, but the medication and/or dosage regimen prescribed must be altered for approval (i.e. a more cost-effective, evidence-based medication or regimen is required). This happens in cases where multiple therapies exist, and some may be substantially more expensive than others, but not have any additional safety or effective evidence to justify the increased cost to the plan.
Claim is declined – This happens in cases where you either do not meet evidence-based clinical criteria for any specialty medication for a given disease-state, or where a medication does not meet established cost-effective thresholds and is not an eligible benefit under a given plan. For example, there are medications on the market today that are not covered by any provincial or federal government plan because the cost outweighs the clinical benefit and therefore is not eligible for coverage.

If I’m approved, am I covered at 100%?

If my claim is approved, do I ever need to have a claim reassessed?

Why is FACET suggesting a different medication than my doctor/specialist?

Can my doctor appeal a FACET decision?