How Canada Life processes prior-authorization drug claims

Key takeaways

Some prescription drugs require prior authorization before reimbursement is considered.
You must submit a form to get prior authorization.
There is an appeal process if your prior authorization is not approved.

What are prior-authorization drugs?

Some prescription drugs require prior authorization before reimbursement is considered. To determine if a drug requires prior authorization, you can:

Use the drug search tool on My Canada Life at WorkOpens a new website in a new window
Call 1-800-957-9777 and speak to a customer services representative
Ask your pharmacy provider using your drug card. If the drug requires prior authorization, the pharmacy will receive a message advising of the prior-authorization requirement.

Once prior authorization has been confirmed, you must work with your physician to complete and submit a Drug Prior Authorization Form.

What are the submission timelines?

You must submit the claim within 15 months from the date the drug is prescribed.

My form is complete. Now what?

Once the prior authorization form is received, signed by the member and physician and all required medical information is included, we will assess the request for coverage of the prior authorization drug under the benefits plan.

How long does it take to process my claim?

Canada Life will review the Request for Information form within 7 calendar days of receipt.

Please note: This timeline is intended for standard plans only. Actual timelines might vary based on plan design and claim complexity. Missing information or incomplete applications for benefits may impact processing timelines. We may need to extend the timeline if additional review is needed.

How will I find out if my claim has been accepted?

Canada Life will contact you by mail regarding the coverage decision.

Appeal level 1

Details – You can appeal our decisions by submitting in writing including any additional medical information from your physician for review.
Timeline – Appeals will be reviewed within 10 calendar days.
Communication – We will respond directly to you in writing with our assessment decision by mail.

Appeal level 2

Details – If you aren’t satisfied with the first appeal decision you may send us in writing all claims details with any additional medical information that we may not already have.
Timeline – Appeals will be reviewed within 10 calendar days.
Communication – We will respond directly to you in writing with our assessment decision by mail.

Complaints

After Appeal level 2, you can ask to have your concerns escalated further. This would flow into our customer complaint process.

What’s next?

Check if your prescription requires prior authorization
Get the prior authorization forms you need.

This information is general in nature, and is intended for informational purposes only. For specific situations you should consult the appropriate legal, accounting or tax advisor.