Trend Management

Express Scripts Canada helps plan sponsors concentrate on achieving the best clinical outcomes for their plan members while avoiding wasteful spending.  Express Scripts Canada defines wasteful spending as allocating funds to medications that cost more, but do not do more for the patient. However, patient health always remains the utmost priority.

Generic Substitution

Generic Substitution can be instituted in two ways with an existing drug plan:

• Voluntary – Multi-source brand drugs are only reimbursed up to the cost of the lowest-cost generic equivalent; however, if the physician writes “No Substitution” or DAW on the prescription, the plan member is able to receive full reimbursement.
• Mandatory – Regardless of what the physician writes on the prescription, only the cost of the lowest-cost generic equivalent will be reimbursed. Any difference in price is the responsibility of the plan member.

Prior Authorization

The Prior Authorization program is a process whereby specific drugs are clinically reviewed prior to allowing their coverage. Many new drugs are very expensive or they have a high potential for inappropriate use. Use of the Prior Authorization program helps to ensure that these drugs are used appropriately to minimize pharmacy-benefit waste which will further ensure that these drugs will be available to those who need them.

New drugs are reviewed by Express Scripts Canada to determine if they are candidates for Prior Authorization. Drug-specific forms and clinical criteria are developed for drugs deemed to be suitable. Using a combination of online messages, physician contacts, and clinical evaluations, the Prior Authorization process helps plan members receive approval for reimbursement under their plans for these drugs in a timely manner. Learn more.

Prior Authorization Request Forms

Analytics (Formerly Rx Reports)

Analytics is a series of 15 pre-defined, online detail and summary reports that customers use to assist in the management of prescription drug benefits. Prescribing patterns and ranking measurements help identify drug-usage trends by therapeutic class and individual drug. Reports are available by group, pharmacy provider, or drug. Additional ad hoc reports are available on request from an extensive database to gather information on the performance of a group’s drug plan. Learn more.

Dynamic Maintenance Drugs

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 claim history to determine whether plan members qualify.  Learn more.

Specialty Drug Programs

Some provinces have introduced Specialty Drug (SD) Programs which pay for the entire or partial cost of therapy for diseases requiring expensive drugs. In most cases, income testing is used as a criterion to determine people’s accessibility to the programs. Learn more.

Hospital Drug Program

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. Learn more.