FACET Specialty Drug Approval Benefit

Your health is our priority. If you or a dependent is prescribed a specialty, high-cost medication for a complex condition, our specialty drug prior authorization program, called FACET will ensure you receive the best drug. A clinical pharmacist with expertise in the disease being treated will assess and manage your claim to ensure a comprehensive, quick and collaborative client experience.

Cubic Health, an independent third party, administers the FACET program and does not share any of your personal or medical information with the University of Alberta. 

Eligibility

Check whether you’re eligible for FACET by accessing your Sun Life account (see instructions under Process below). 

Specialty drugs

Specialty drugs are those used to treat specific medical conditions and typically cost more than $5,000 per year. To find out whether the drug your physician is considering or has prescribed requires FACET prior authorization, visit facetprogram.ca and choose “Find my form”, then type in the name of your drug. Forms for medical conditions relevant to your drug will be available for download.

Covered conditions

Dozens of disease states that use specialty drug are included under the FACET program, but the most common include:

  • Asthma/COPD
  • Cancer
  • Chronic migraines
  • Crohn’s disease/ulcerative colitis
  • High cholesterol
  • Multiple sclerosis
  • Psoriasis
  • Rheumatoid arthritis
Plan members currently prescribed a specialty drug

FACET’s prior authorization will impact all plan members prescribed a new specialty drug after March 1, 2021. 

Employees prescribed a specialty drug before then will not be impacted until there is a change in dose or drug. Approvals are grandfathered indefinitely, unless Sun Life had previously communicated a termination date of the approval to the member. If there is a defined termination date, FACET would review the renewal at that time to ensure ongoing effectiveness and safety.

New FACET approvals are valid for one year.

FACET Process

  1. Starting March 1, 2021, you can find out which prescription drugs require FACET prior authorization by logging in to Sun Life’s app or website.
    • Once you’re logged into the website, select Coverage Information from the landing page. On the next page, choose Drug Coverage > Drug look up > Review the terms and conditions > type in your drug name or Drug Identification Number. 
    • Once you’re logged into the app, select Coverage Information from the home page. On the next page, choose Drug > Drug Coverage and scan or type in your Drug Identification Number. 
  2. If the drug requires FACET prior authorization, plan members work with their physician and/or patient support program to fill out a form at facetprogram.ca. You’ll need the plan contract number: 25379.
  3. Decisions are made with three questions:
    • Is a specialty drug needed based on the plan member's individual disease severity, clinical picture, and past drug history?
    • What is the most appropriate drug from a safety, effectiveness and cost- effectiveness perspective? Some drugs may be substantially more expensive than others but do not have evidence of increased safety or effectiveness for the additional cost. 
    • What is the most appropriate dose from clinical evidence?
  4. Decisions are shared with the plan member and their physician. Possible FACET claim decisions:
    • A claim is approved as submitted
    • A claim is conditionally approved: There is an alternate specialty drug(s) or dosing regimen that must be tried first. In these cases, FACET outlines the approved specialty alternatives. 
    • A claim does not meet criteria either because the plan member doesn’t meet clinical criteria for the specialty drug or a drug doesn’t meet established cost effectiveness thresholds and isn’t eligible through our benefit plan. For example, there are drugs on the market today that are not covered by some plans because the proven benefit of the drug is minimal and does not justify the cost of the drug. 
  5. If a drug is approved, the approval details (i.e. Drug Identification Number, effective date, termination date) is shared with Sun Life.
If the claim is not approved as submitted, does that mean the physician is prescribing the wrong drug?

It’s difficult for physicians to keep track of all available drugs, including effectiveness, pricing, new research and new types. FACET’s pharmacists are experts in assessing and recommending the most effective drugs for treating speciality conditions. They work closely with physicians to discuss and agree upon your drug. 

Appealing a decision

Appeals can be made if:

  • The disease state changes
  • There are documented clinical reasons why alternatives are not viable options for you
  • There has been a material change to evidence and research that warrants a review
  • You disagree with FACET's recommendation
Prior authorization validity

Each specialty drug prior authorization is valid for one year. This gives FACET an opportunity to reassess your prescription and ensure the specialty drug remains effective and the best available option for you.

Prior authorization renewal

To renew your specialty drug, please have your physician complete parts six and 10 of the FACET Prior Authorization Form prior to the end of the approved authorization period. FACET will reassess your prescription.

About FACET

With approval from the Support Staff Benefits Committee and the Academic Benefits Management Committee, the university appointed the FACET program to ensure plan members have the best available drug and care for their condition, and to ensure the costs of specialty drugs are carefully assessed so that the employee benefit plans remain sustainable. 

FACET manages claims quickly -- typically within 48 hours. The program has no financial connection to a claim and has no incentive to modify a claim, allowing them to remain unbiased. FACET’s pharmacists are focused on cost effectiveness and evidence-based clinical criteria with no financial incentive to modify a physician’s request. Most plans are focused on the drug being requested; FACET’s focus is on the condition being treated.

For more information, visit facetprogram.ca.