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Frequently Asked Questions
The following questions will be of interest to dental and pharmacy benefits customers. Questions are arranged by subject:
Prior Authorization
What is Prior Authorization (PA)?
Express Scripts Canada's Prior Authorization program is a process whereby specific drugs are clinically reviewed prior to allowing them to be eligible to be covered by a benfits plan. Many new drugs are very expensive; others may not be used appropriately. Your plan may require Prior Authorization for some of these drugs. Prior Authorization helps benefits-plan managers to ensure that these medications are used appropriately, so they will be available to those who need them.
New drugs are reviewed by Express Scripts Canada to determine if they are candidates for PA. Drug-specific forms and clinical criteria are developed for drugs deemed to be suitable for PA. Using a combination of online messages, physician contacts, and clinical evaluations, the Express Scripts Canada Prior Authorization process helps plan members receive approval for reimbursement from their benefits plans for these drugs in a timely manner.
How exactly does the Prior Authorization work?
Drugs that have been determined to be eligible for the PA program will be covered only following the completion of a PA form by both the plan member and prescriber. These PA Request Forms are available in PDF format for members to download and print.
In the event that a plan member attempts to have a PA drug filled at a pharmacy prior to completing a PA form, the pharmacy will receive an online message indicating that payment for the drug is conditional upon approval under PA, and that they must call Express Scripts Canada.
Upon contacting Express Scripts Canada's Call Centre, the call-centre member advisor can direct the pharmacist to the Web site or provide direction with respect to sending a PA Request Form, via facsimile, to the pharmacy.
The plan member will then have to complete the required sections of the form, including the authorization to disclose health information and bring the form to the prescriber for further completion. The form will then be faxed to Express Scripts Canada, where it will be evaluated by our clinical staff to ensure that the use of the drug meets established criteria.
Express Scripts Canada will inform the plan sponsor and plan member of the decision to approve or deny payment of the claim under the PA criteria. This process can also be completed prior to a plan member receiving a prescription for a PA drug.
Which drugs require prior authorization for inclusion on the DTF list?
The following list indicates the drugs which require Prior Authorization from the Employer/Insurance Company. Approval depends on whether specific criteria for using these drugs are met. Please see your plan administrator for details.
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How does PA work?
If you have been prescribed a drug requiring a prior authorization, you have two options:
(a) You may want to get approval for coverage before filling your prescription
(b) You can fill your prescription first, pay for it and go through the PA process thereafter.
a) You may want to wait until you have received approval for the prior authorized drug to get your prescription filled.
- Obtain the PA Request Forms: The forms are available on Express Scripts Canada’s Web site, at www.express-scripts.ca, and can be accessed and printed by anyone (e.g., patient, pharmacist, physician or plan sponsor). Another way to access these drug forms is through your pharmacy. When the pharmacy submits your prescription to Express Scripts Canada for a drug requiring Prior Authorization, it receives an online message indicating that payment for the drug is conditional upon approval under PA, and to call Express Scripts Canada. The pharmacy contacts Express Scripts Canada's Call Centre by telephone and the call-centre member advisor can direct the pharmacist to the Web site, or send a PA Request Form, via facsimile, to the pharmacy.
- Fill out any required sections on the form, including your authorization to disclose health information. You must take the form to your physician to complete. If your physician charges a fee to complete the form, you are responsible for paying the fee.
- The completed PA form has to be returned by fax to (905) 712-6329 or send by standard mail to Express Scripts Canada.
- A clinical pharmacist at Express Scripts Canada evaluates the completed PA form to ensure that you meet the established criteria. Upon receipt of a form containing all required information, it will take two-five business days to evaluate and update your profile.
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If the PA is approved:
- The carrier or Express Scripts Canada updates your profile to allow for payment of the drug.
- The carrier or Express Scripts Canada sends you a letter indicating that the PA has been approved.
- You must contact your pharmacy to pick up your prescription or arrange for delivery.
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If the PA is denied:
- The carrier or Express Scripts Canada updates your profile to deny payment of the drug.
- The carrier or Express Scripts Canada sends you a letter indicating that payment for the drug has not been allowed.
b) Otherwise, you may pay for your prescription immediately and mail a paper claim to your insurance carrier for processing.
- However, the PA request must still be done and you will not be reimbursed until you receive PA approval. If, after the PA process [step (a) above] is completed, the drug is not eligible under your group plan, you will not be reimbursed for the cost of the prescription.
Since there is an additional step before you can fill a prescription, it may take a little longer to get your medication. If your doctor is not available to complete the PA form, it could take additional time before you can receive Prior Authorization for the PA drug.
The PA process ensures that you receive necessary health benefits without compromising quality of care. Only medically approved treatments are paid for, based on a review of the clinical literature. Prior Authorization distances your insurance provider and plan sponsor from making decisions about coverage for new prescription drugs while maintaining your confidentiality. As well, you do not have to submit manual claim forms using this process.
If you have any questions about the PA process, please contact your plan administrator.
NOTE: Express Scripts Canada offers its customers different products.Express Scripts Canada customers who decide which of these products will be offered through their own programs. Some products may not be available in all provinces/territories.
Dynamic Maintenance Drugs
What is the Dynamic Maintenance Drugs process?
Dynamic Maintenance Drugs (DMD) is a process that determines whether or not plans will pay for up to 100 days of supply of a plan member’s medications. This process uses claims history to determine whether plan members qualify for up to 100 days of supply.
How does the DMD program work?
The system checks each prescription to see how frequently it is being filled. Depending on prior use, the system will determine if the drug being dispensed should be deemed as a maintenance drug or a non-maintenance drug. If the drug is deemed non-maintenance, the claim is cut back to 34 days.
The DMD program will treat any drug as a maintenance drug once plan members have been stabilized on the drug for omore than 88 days. At the physician’s discretion, up to a 100-day supply will be allowed following stabilization on the same drug and same dosage. If plan members have not received a maintenance supply for a drug that they have been stabilized on for more than 88 days, then a message will be sent to the pharmacy indicating that they can now have a maintenance supply. The pharmacist will have to contact the physician in order to have the prescription changed.
After determining if a drug is maintenance or non-maintenance, the system will process the claim as usual.
When will DMD begin?
The program requires that there must be at least four months of claims history in the system.
What are the advantages of DMD?
- This program can reduce drug waste and promote positive patient outcomes.
- There is the potential to eliminate waste in the event that the prescription needs to be discontinued or changed. This means that a 100-day supply will not always be dispensed the first time a prescription is filled.
- The DMD process analyzes medication history for the appropriate dispensing of chronic-care medications.
- The pharmacist will enhance plan-member care by participating in this program. Specifically, the pharmacist will use professional skills and judgment since appropriate quantities will be dispensed based on the plan member’s prior history.
- The pharmacist can assess the plan member’s ability to comply for the full term of the prescription, and determine whether the plan member will need to be re-assessed by a doctor before using all the medication dispensed.
- In addition, the pharmacist can ascertain if there is any other reason or existing condition that would indicate that dispensing a maintenance quantity of medication would be detrimental to the plan member’s health.
Specialty Drug Programs
What are Specialty Drug Programs?
Some provinces have introduced Specialty Drug Programs (SDPs), which pay for the entire or partial cost of therapy for diseases that require with drugs that are expensive. In most cases, income testing is used as a criterion to determine people’s accessibility to the programs. In a few cases, all people with the condition are eligible.
How do SDPs differ from a hospital drug program?
The criteria for hospital drug programs are based on whether a drug is only administered in a hospital setting under close supervision, and whether it is applied to all drug plans using this functionality across Canada. SDPs are provincially funded, which means that the drugs covered by these programs are province-specific.
SDPs cover drugs used for specific diseases or conditions, such as an organ transplant.
How do SDPs work?
Express Scripts Canada has a process through which to handle SDP programs that does not rely on income tests.
Express Scripts Canada can only code drugs that meet the following criteria:
- The drug is uniquely used to treat one condition
- The SDP is available to everyone in the province
- The SDP does not rely on income or means testing
Using a combination of online messages and clinical criteria, the SDP process ensures that claims for plan members are submitted to the specific provincial SDP before they are submitted to a group benefits plan.
How often does Express Scripts Canada review drugs that are covered by SDPs?
Express Scripts Canada reviews drugs covered by SDPs on an annual basis. Periodically, Express Scripts Canada reviews provincial SDPs for revisions. Express Scripts Canada then notifies its customers of any changes to provincial coverage.
If a plan member is eligible for a drug funded by a provincial SDP, who pays for the drug?
SDPs are the primary payer for the drugs covered by the specific program.
How does a SDP work in Quebec?
SDPs work differently in Quebec. Drugs mandated to be covered by a pla, according to Régie de l'Assurance Maladie du Québec (RAMQ), would automatically be covered.
What is the advantage of using the SDP process?
The SDP process ensures that specific provinces are the primary payers for these drugs. This saves money for plan sponsors since they are not the primary payers for SDP drugs.
What are the potential disadvantages of the SDP process?
By introducing an additional step before an employee can fill a prescription, some inconvenience may be experienced by the plan member.
How will pharmacists know that a claim is rejected because of the SDP process?
Pharmacists receive a message “QQ – DRUG INELIGIBLE – SPECIALTY DRUG PROGRAM” when they
submit a claim on behalf of a member who should have coverage for a drug through a provincial SDP.
How much does it cost to implement the SDP process?
The cost to implement SDP depends on the carrier’s internal cost of processing patient exceptions and handling telephone inquiries from plan members and plan sponsors about rejected claims. Additional costs may be incurred for processing paper claims.
What are the potential savings of the SDP process?
By implementing the process, plan members taking drugs that are eligible under a SDP will have the drug paid for by the provincial government instead of the group insurance plan. There are very limited drugs covered by provincial SDPs for all residents of a province. Most programs are based on income; therefore the overall savings to a plan would be minimal.
Where can plan members get information regarding the various provincial SDP?
The following is a list of programs currently in place:
Alberta
Province-Wide Services for Alberta
University of Alberta Hospital Outpatient Pharmacy
(for information on HIV, Cystic Fibrosis, and Organ Transplant medications)
(780) 407-6990
British Columbia
B.C. Organ Transplant Society
(800) 663-6189
(604) 877-2240
B.C. Centre for HIV/AIDs Treatment Program
(604) 806-8515
Ontario
Special Drugs Program
(800) 268-1154
(416) 314-5518
HOSPITAL DRUG PROGRAM
What is the Hospital Drug Program (HDP)?
Some drugs are primarily given in a hospital setting as they require extensive monitoring with medical or nursing expertise due to the severity of condition they treat, complex route of administration (e.g., intravenous infusion), or potential safety concerns.
The Express Scripts Canada Hospital Drug Program (HDP) contains a list of those drugs that are intended to be administered in hospital on an inpatient or outpatient basis, and should not be paid by a private drug plan. Examples of drugs included within this program are chemotherapy drugs and antibiotics given by injection.
How does the HDP differ from the Specialty Drug Program (SDP)?
The criteria for the HDP are based on whether a drug is intended to be administered in a hospital inpatient setting or as part of a complex treatment regimen carried out in a hospital outpatient setting by specially trained personnel. These criteria are applied to all drug plans using this functionality across Canada.
Only drugs which fit the aforementioned criteria are included in the HDP. Drugs under the SDP are provincially funded, which means that coverage is province-specific. The SDP covers drugs used for specific diseases or conditions, such as organ transplant and HIV, and includes drugs which may be taken at home.
How does the HDP work?
Using a combination of on-line messages and clinical criteria, the HDP process alerts pharmacy providers that claims for drugs, which are intended to be administered in a hospital setting, should not be paid by the group benefits plan. Claims will be rejected when a pharmacy submits these types of prescriptions for payment by Express Scripts Canada.
How often does Express Scripts Canada review drugs that are covered by the HDP?
Express Scripts Canada’s Drug Evaluation Committee (DEC) evaluates drugs included on Health Canada’s Notices of Compliance (NOCs) List each month to determine if these drugs should be classified as hospital drugs. Only drugs that require monitoring and are intended to be administered in a hospital setting are classified as hospital drugs.
How does the HDP work in Quebec?
HDP works differently in Quebec. Drugs mandated to be covered by a plan, according to Régie de l'Assurance Maladie du Québec (RAMQ) would automatically be covered.
What could be the advantage of using the HDP process?
The HDP process ensures that drugs administered in a hospital setting are not paid by private payers. This saves money for plan sponsors as claims will be rejected, and they will not be responsible for costs of HDP drugs.
What are the potential disadvantages of the HDP process?
There may be some situations in which a patient is asked to pay for a drug that is on the HDP. By introducing an additional step before a plan member can fill a prescription, some inconvenience may be caused to the employee.
How will pharmacists know that a claim is rejected because of the HDP?
The pharmacy will receive a message “QP – DRUG INELIGIBLE – FUNDED BY HOSPITAL BUDGET” – when it submits a claim for a plan member who hs drug coverage through the HDP. There may be cases whereby a drug is administered in a hospital setting but is not covered by the hospital budget/provincial program; however, because the site of administration is within a hospital setting, the private drug plan should not pay for these claims in the majority of cases.
How much does it cost to implement the HDP?
The cost of HDP depends on the carrier’s internal cost of processing patient exceptions and handling telephone inquiries from plan members and plan sponsors about rejected claims. Additional costs may be incurred for processing paper claims.
What are the potential savings of the HDP?
By implementing the process, plan sponsors will not be required to pay for drugs that are administered in a hospital setting on an in-patient or out-patient basis. Potential savings to the plan have been estimated at 1%-2% of total plan costs.
Dynamic Therapeutic Formulary
How does the Dynamic Therapeutic Formulary work as part of a tiered plan?
The basic principle of having a two-tiered component is to provide a greater level of reimbursement for more cost-effective therapies on the Dynamic Therapeutic Formulary (DTF), while ensuring that members still have access to other prescription drugs as required.
Tier 1
The first tier of the DTF includes clinically sound and cost-effective preferred drugs for the most highly used drug classes. All the drugs listed on this tier will be covered at a higher level of reimbursement. The vast majority of drugs are covered on the first tier.
Tier 2
The second tier is an open plan design that can be chosen by the plan sponsor. It may include all drugs excluded from the first tier. The second-tier prescription items are reimbursed at a lower level. The plan member continues to have access to all prescription drugs, yet the plan design structure encourages the use of the cost-effective preferred drugs on the first tier. The second tier encourages the use of lower-cost equivalents wherever available.
What drugs are covered in the DTF?
Express Scripts Canada reviewed the most clinically effective and cost-effective treatments for inclusion in the DTF, while it ensures the availability of treatments for most disease states.
How does this plan compare to other prescription drug plans?
The DTF covers the majority of items found on a typical prescription requiring drug plan. The drugs not covered are the ones with no significant clinical advantage over the existing, more cost-effective treatments. Certain discretionary drug categories are not covered; these items could be covered by the second-tier prescription-requiring plan at a reduced rate of coverage. The major difference the DTF has over a typical prescription plan is all new drugs are reviewed, according to the DTF plan criteria. This is done each month to determine which new drugs are appropriate to be added to the DTF.
In addition, the maintenance of the DTF is a dynamic process where drugs are reviewed semi-annually (January and July). This process ensures existing DTF drugs are still clinically and cost-effective treatments and makes sure that the most recent medical information gets reviewed.
Are there drugs that require Prior Authorization on the DTF?
There are drugs on DTF Tier 1 that require Prior Authorization (PA). It requires plan members to submit medical information from their physician to their insurer for approval in order for a particular expense to be covered. PA is used to gather additional medical information to confirm the drug is being used for an eligible condition. Prior Authorization is a component of claim-management practice and ensures that the plan does not pay for drugs that are not eligible. Click here for a list of drugs that require PA.
Prior Authorization criteria are generally applied to drugs that:
- Have multiple indications
- May be used off label for an indication approved for another drug
- Have high costs and are not considered a drug of first choice, because of less efficacy and/or more side effects, or have not clearly demonstrated that they are as cost-effective as other drugs
- Will typically be administered in a hospital setting if medication is not taken orally
- Will take into consideration any Provincial Special Funding Programs that may be available for a drug
Is generic drug usage incorporated into the DTF?
Generic substitution plan design will be applied to the DTF. With this feature, the patient will be reimbursed at the cost of the lowest-cost interchangeable generic in the dispensing province.
Who decides what is covered in the DTF?
A team of clinical pharmacists reviews new drugs to determine if they should, or should not, be covered on the DTF based on clinical and cost-effectiveness. More information regarding this process is available upon request.
How often is the DTF updated?
The DTF is updated each month after the team evaluates new drugs.The entire DTF is reviewed semi-annually (January and July) to ensure existing clinically cost-effective treatments are still appropriate.
Are any drugs automatically included or excluded in the Express Scripts Canada Dynamic Therapeutic Formulary?
Express Scripts Canada Dynamic Therapeutic Formulary |
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Copies of drugs (i.e., generics) already included in the plan:
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Hospital drugs:
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How does this plan help contain costs?
The lower cost of DTF drugs offsets their increased member-reimbursement level, reducing the overall cost to the plan. When a plan member works with their physician to choose a drug from the DTF list, they will be reimbursed at the highest co-insurance level. The design encourages plan members to use more cost-effective drugs, while still providing the flexibility to choose most other prescription drugs at a lower reimbursement level. In many cases, Express Scripts Canada can analyze a current plan and provide the estimated savings of moving to the DTF.
What types of communication are available?
Plan members should be continuously updated on the DTF because of the dynamic nature of the plan. Managing the plan member’s expectations is very important so that there are no surprises when a drug that was previously covered by the DTF is no longer covered, or when new drugs are added to the plan. Express Scripts Canada maintains a list of covered drugs and alternatives for non-covered drugs to assist in member communication.
Express Scripts Canada is not in a position to discuss individual patient therapy or recommend alternative drug options with patients. If a member has questions about the drugs covered in their plan, they will be instructed to contact their plan administrator.
How does the DTF work in Quebec?
Both the DTF and the second-tier prescription-requiring plan include items which appear on theRégie de l'Assurance Maladie du Québec (RAMQ) formulary. As a result, for Quebec-based plans, it is recommended that reimbursement of each tier be set equal to, or greater than, the RAMQ minimum requirements of 69% (e.g., DTF @ 90%, Rx Requiring Plan @ 69%). If, however, the plan sponsor chooses to set either tier at less than the RAMQ minimum, RAMQ logic will ensure that items that are on the RAMQ formulary continue to be reimbursed at the RAMQ minimum requirements.
Why should plan sponsors consider the DTF plan?
Plan sponsors need to manage their drug plan and educate plan members so they become better medical consumers. Expected trends over the next 10 years suggest that costs for unmanaged plans will increase at a much greater rate than costs for fully managed plans. Effective management of the drug plan cannot change the trends, but it will help to stem the tide.
