FACET Appeals Process

The objective of FACET's Appeal Division is to implement an equitable, objective, and consistent process to re-evaluate prior FACET decisions under specific criteria.

An appeal will be reviewed by two pharmacists, separate from the original pharmacist that reviewed your case.

An appeal will be considered under the following circumstances:

	The underlying disease state has changed materially since the initial FACET decision was rendered and a subsequent review of the claim is warranted.
	There are documented and justifiable clinical reasons why specified alternatives are not options for a given patient in a given case.
	There has been a material change to the underlying primary evidence-base that warrants a review.

Criteria for the OTIP FACET Appeal Process

An appeal will only be considered once a primary Prior Authorization decision has been rendered by FACET. An initial decision can be appealed for up to one (1) year after it has been rendered. Appeals received after this period will be handled as new reviews.
An appeal will only be considered after other Provincial and/or Federal programs that may provide coverage are pursued and documentation can be provided of these relevant requests for public funding.
No appeals will be considered for drugs that are specifically excluded under the plan's extended health plan, or for any drugs that are subject to annual or lifetime maximums as defined under the member's plan contract.
An appeal must be made within three (3) months of the primary decision.
Appeal adjudication will be based on balanced consideration of evidence of the effectiveness of a given drug therapy to treat a specific condition as reviewed by a Canadian Health Technology Assessment (HTA) body (i.e. Canadian Agency for Drugs and Technologies in Health), or if unavailable, similar and relevant HTA bodies in other jurisdictions, a drug's place in therapy, the availability of alternative therapies, and the cost-effectiveness of the product in question as reviewed by a credible HTA body.
If the drug under appeal is considered a second-, third-, or fourth-line agent for the treatment of a given condition according to its indications and/or clinical practice guidelines, explanation(s) and evidence of treatment failures with other agents may be required.
Any drug being considered for appeal must be prescribed by a specialist for the disease state/condition in question.
All decisions are made by licensed, independent clinical pharmacists with experience in reviewing Prior Authorization claims and appeals, and who have no financial interest in the claim and therefore render objectivity in assessing each appeal.
Clinical decisions will be made within five (5) business days from the time that all necessary information is received on a given case.

FACET Appeals Process

Criteria for the OTIP FACET Appeal Process

The Process

Step 1

Step 2

Step 3

Step 4