To look up the prescribed drug name:

1. Go to www.otip.com and click Log in.
2. Select Health and Dental from the drop-down menu and log in.
3. After you have logged in, click My Claims.
4. Select My drug plan under My benefits list.
5. Enter the information for your search to find out if the drug is covered by your benefits plan or if prior authorization is needed. You can also check the approximate out-of-pocket expense (if any) to purchase the drug, as well as any alternatives (e.g. generic version of the drug).

If your doctor has prescribed a drug for you, or one of your eligible family members, that needs prior authorization, you will need to complete the Drug Prior Authorization Request Form found on pa.otip.com. 

 

Submit your completed Drug Prior Authorization Request Form to FACET. A decision will be communicated to you within 2-3 business days.

• If the drug is not covered*, or the criteria for approval is not met, you will receive notice of the decision from FACET. The notice will provide a detailed explanation and the next steps for you to consider or discuss with your doctor.
• If you receive conditional approval, your prescribed drug may be approved with a change in dosage or an alternate drug therapy may be recommended for discussion with your doctor. If an alternate drug therapy is recommended, you will not need to submit a new Drug Prior Authorization Request Form.
• If your prescribed drug is approved, it will be covered under your benefits plan and approval details will be provided to you by FACET.

*If your requested drug is not approved, you can expect to receive a call from a Medication Access Coordinator (MAC). The MAC is a medication reimbursement specialist who will walk you through the decision and discuss the next steps or possible alternatives. If there are medical reasons why the decision rationale does not apply to you, visit pa-appeals.otip.com for information on submitting an appeal.

Drug prior authorization helps you to understand if and how much of the cost of a medication, or of any alternative treatment, is covered by your benefits plan.

You can use the online tool, My Drug Plan, to look up a drug and find out if prior authorization is needed.

When a drug prior authorization request is approved, it will include details on how long the approval is for and when you may need to provide any additional information.

• Your Employee Life and Health Trust (ELHT) makes plan design, funding, administrative and investment decisions in the best interest of its plan members.
• OTIP administers your benefits on behalf of your ELHT and answers your questions about enrolment, eligibility, benefit premiums, funding arrangements, and life, health and dental claims.
• OTIP has chosen Cubic Health's FACET Program to administer the drug prior authorization program using evidence-based clinical criteria and plan design considerations. The FACET Program provides:
  • Helpful service and support to navigate the prior authorization process.
  • Independent and evidence-based clinical assessment of your prior authorization claim.
  • Timely reimbursement decisions that are communicated directly to you and your doctor.
• Your benefits plan may have designated MemberRx as the exclusive pharmacy distributor for certain specialty medications. This means that certain drugs will only be covered by your benefits plan if dispensed by MemberRx. If you receive approval for a drug that will need to be dispensed to you by MemberRx, you will be referred to MemberRx by the FACET Program. MemberRx will contact you directly to arrange the delivery details for your first prescription.
• Manulife is the insurer that pays health and dental claims and issues life insurance on behalf of your ELHT. Manulife is not involved in any drug prior authorization decisions.