If the response of the physician points toward the criteria, we are going to authorize the treatment. If not, then we'll ask why they are not trying the first line and second line.
I would say physicians are busy people. They want to do good for their patients, and sometimes they may feel this is pressure on them, but all plans in Canada have a certain level of, I would say, limited use where you go back to the physician to ask for evidence.
As I've mentioned before, this is a small percentage. Ninety-six per cent of the claims we receive for drugs are paid at the counter of the pharmacy. The patients show up at their pharmacy, pharmacists fill the prescription and send us the bill, and the client leaves with the drugs. It's 96%.
There is a small percentage, and we are trying to look at opportunities all the time to change our status or refine our criteria to avoid having to go back to the physician, but sometimes it is the result of a client safety situation so we will go back to the physician and ask, “Could you please explain, because we see a problem?” There might be contraindications about the two prescriptions the patient is on. We have the information. It would not be responsible to not act on that.
Most of the time we get the answer, and we process that in half a day because all this is done electronically between the pharmacy desk, our drug exception centre, and the physician's office, and we try to expedite the process. We have put a higher scrutiny on children more recently because there seemed to be a sensitivity there to make sure our rules are up to date.
The other reality is that, since we are operating in 13 jurisdictions, the fact that some provinces use different processes is a bit confusing for people on the ground sometimes. This is because most of their clients will be covered by the provincial plan, for example, and an odd case will be covered by us, and they are not totally aligned or knowledgeable about our processes.
This is one of the challenges of being a very large plan distributed across the country. We are small everywhere, so we cannot really influence the practice. We have to learn about that all the time.
There was an issue in one of the provinces recently about one product. We were hearing an ongoing complaint about the fact that we denied coverage of that. It was only in that province because suddenly the provincial plan started to cover this product, and physicians started to prescribe that product there, and we were not aligned with them. There is a due diligence that we have to try to learn about what is changing in the provincial formularies so that we can take that into account in the way we administer products.