The complaint: Niles contacted us with a complaint about the Special Authority program at Pharmacare. Special Authority grants full or partial coverage to a drug or device that otherwise would not be covered or would be only partially covered. Coverage is provided to patients in specific medical circumstances. Niles’s wife, Nelly, required a transmitter for blood sugar monitoring that cost $900 for a three-month supply. Nelly’s doctor applied for Special Authority approval well in advance of her supply running out. After several unsuccessful attempts to have the request approved, the doctor advised Nelly to buy a new transmitter to avoid medical complications.

What we did: During our investigation, we consulted Pharmacare staff, who told us there was a significant backlog on Special Authority applications. We also learned that under the current framework patients are not reimbursed if they purchase a transmitter without first getting Special Authority approval for renewal. We were concerned about the fairness of this situation, as Nelly’s doctor was unable to get the request approved in time despite his best efforts and timely application.

How we helped: As a result of our investigation, Pharmacare issued a backdated five-year Special Authority coverage for Nelly and agreed to refund the cost of her transmitter.

To address the backlog of applications, we suggested that Pharmacare update its website to reference current processing timelines and to advise medical professionals not to apply more than once. Pharmacare agreed.

“We have received the money for reimbursement of funds … I cannot thank you and your office enough for your service. I was nowhere without your help.” – Niles and Nelly

Why it matters: Administrative delays like the one experienced by Nelly can lead to costly and potentially dangerous outcomes. When there is a delay, authorities need to make sure individuals are not negatively impacted while a decision is being made.