From Savings to Support: Understanding the Value of the FACET Program

Why FACET Was Chosen

Prior Authorization for the CUPE EWBT plan was initially managed by Canada Life. In January 2024, CUPE EWBT began using Cubic Health’s FACET Prior Authorization Program for assessing the reimbursement of claims for complex, high-cost specialty medications.

FACET’s independent medication experts use a transparent, evidence-based approach centered on member care, removing any financial influence around what may or may not be covered when specialty medications are prescribed. The FACET Clinical Team brings deep expertise and scale, allowing them stay current on the latest evidence and new therapies across more than 200 diagnoses, enabling them to provide an objective review of treatment options. This independent, second set of eyes on a Prior Authorization claim is there to ensure the optimal medication is being covered at the right dose at the right time.

FACET has been independently managing Prior Authorization claims for a decade and has completed tens of thousands of reviews across hundreds of thousands of employee lives across Canada. The FACET Program is in place with every education sector Benefits Trust in Ontario, in some cases dating back over 5 years.

In addition to an independent, objective and transparent review of Prior Authorization claims, FACET was chosen by CUPE EWBT for several key reasons, including:

• The speed at which member claims are assessed;
• Direct access to the FACET team for both members and their physicians;
• Compassionate support for members when a claim cannot be approved; and
• Detailed quarterly reporting on program metrics.

Exceptional Turnaround Times

In the first 14 months that CUPE EWBT’s FACET Program has been in place:

• Reviews completed either the same day, or the next day:
  • 97% of claims for specialty drug therapies, and
  • 90% of claims for GLP-1 Agonists used in Type 2 Diabetes and Chronic Weight Management.

This is notable because FACET has had to actively clinically intervene on over 50% of new Prior Authorization claims for specialty drugs and 30% of claims for GLP-1 agonist medications used in treating Type 2 Diabetes and Chronic Weight Management.

FACET’s Concierge Clinical Support

Following a detailed clinical review of requests submitted, the FACET team arrives at one of three possible decisions related to the plan’s reimbursement of a claim. This outcome is then shared with both the member and their physician, along with the rationale behind the decision:

1. Approval as Submitted – this means the prescribed medication and dosage requested are determined to be the most appropriate in that case.
2. Conditionally Approved – the course of therapy is appropriate but a change to the prescribed medication and/or dosing is required before it can be reimbursed through our plan. In these instances, FACET works directly with prescribing physicians to look at alternatives.
3. Declined – this happens when a claim cannot be approved because the clinical criteria haven’t been met, or when there are no other non-specialty medication alternatives that can initially be tried (and covered under our plan). In these cases, FACET’s team of Medication Access Coordinators (MAC) work with members to attempt to secure coverage through various publicly funded and/or compassionate use programs.

The end result? Better health outcomes through concierge care for members and cost savings for the plan.

It is important to note that FACET Prior Authorization reviews are not determining whether a Physician can or cannot proceed with a certain treatment plan. FACET does not question the underlying diagnosis. The focus of the Prior Authorization review is on providing a decision with respect to what the plan will reimburse for drug therapy. In the case of a Conditionally Approved claim or a Declined claim, if a Physician wants to reject a FACET decision and proceed with the medication initially requested, they are welcome to do so. The only consideration is that the plan will not reimburse the medication in question. In this case, a member may look to a secondary plan for coverage and/or apply for any relevant public funded coverage.

You can learn more about the details of FACET’s full PA process in our Q4 blog.

What Kind of Impact has FACET Made?

Helping to Prevent Inefficient or Ineffective Plan Spending

The independent clinical review of PA claims through FACET supports members receiving the most appropriate, evidence-based treatment that offers the best outcomes. It also helps to avoid unnecessary plan costs from medication regimens or therapies that aren’t considered to be cost-effective based on independent Health Technology Assessment (HTA) and/or based on other appropriate therapeutic options available.

By helping to prevent inefficient or ineffective plan spending—such as when a requested medication isn’t clinically appropriate or isn’t the best option for an individual’s clinical situation—FACET helps ensure limited Trust resources are used wisely. And as a result, helps to ensure that limited plan resources can be reinvested elsewhere to help protect current levels of benefit coverage together with long-term plan sustainability.

Return on Investment

Since the FACET Program launched in January 2024, spending on high-cost specialty medications has been reduced through improved, cost-effective therapy alignment. This has enabled CUPE EWBT to redirect funds that would have otherwise been spent, supporting the broader claims needs of all members. Between January 1, 2024, and mid-March 2025:

• 3,212 reviews were completed:
  • 1,223 specialty drug claim reviews completed;
  • 1,989 reviews of GLP-1 medications to treat Type 2 Diabetes and Chronic Weight Management, given that weight loss was an approved benefit during the first year of the FACET Program.

When Decisions Are Evidence-Based, Trust Follows

Importantly, none of the 3,212 completed reviews resulted in complaints from Specialists related to the clinical rationale used to make a decision. This is because of the transparent, evidence-based approach the FACET team uses and the fact that every complex specialty drug claim is managed end-to-end by an independent, licensed, Doctor of Pharmacy (PharmD) credentialled medication expert who has no financial interest in a claim. If a Physician has any concerns related to the clinical rationale used in decision making, they can appeal the decision.

You can learn more about CUPE EWBT’s PA for high-cost specialty drugs (just click the link), to help ensure your specialty medications are approved for coverage before they are dispensed by your pharmacy.

Spring 2025 Reminders and Updates

Have more questions about the prior authorization of specialty prescription drugs or your coverage in general? Check out our Plan Overview, or visit our Contact Us page to get in touch with the right contact for your inquiry.