As increasing prescription drug costs threaten the sustainability of employer benefit plans, traditional clinical products and services are not enough. Express Scripts Canada provides solutions that reduce waste, ensuring the viability of benefit plans, while optimizing health outcomes.
Our solutions are based on Health Decision Science. This evidence-based approach enables better plan member decisions, resulting in lower costs.
Under the guidance of our experienced clinical team, we leverage a number of diverse formularies and programs to help our clients manage drug plan costs. We work closely with plan sponsors to develop flexible, cost-effective strategies that meet their specific needs.
Express Scripts Canada offers several tools to help plan sponsors determine which prescription medications should be covered by their plan. We offer a wide array of open drug plan design options and features to accommodate the unique needs of each and every client. Tiered formularies can help guide plan members toward equally effective, lower-cost options.
The Express Scripts Canada Dynamic Therapeutic Formulary (DTF) is a two-tiered formulary that combines the benefits of a managed formulary with the flexibility of a traditional drug plan.
The DTF consists of a defined list of drugs that are reviewed on a monthly basis to assess their therapeutic effectiveness and determine the most effective and affordable alternatives for patients.
The DTF is designed to:
Click here to access the Express Scripts Canada Dynamic Therapeutic Formulary.
We help plan sponsors concentrate on achieving the best clinical outcomes for their plan members while avoiding wasteful spending. The following options help clients manage spending without compromising patient health.
Substituting brand drugs with equally effective generic drugs is the first line of defence against wasteful spending.
Prior Authorization Program
Express Scripts Canada’s Prior Authorization (PA) program confirms that high cost drugs are prescribed for the treatment of Health Canada-approved indications and must be used according to standards of care. This reduces costs and allows the plan to continue to cover high cost drugs for plan members who need them. The majority of the PA drugs are specialty drugs used for the treatment of complex, chronic conditions such as cancer, multiple sclerosis, rare diseases, and severe inflammatory conditions.
Step Therapy Program
Express Scripts Canada’s Step Therapy Program provides real-time claim responses to encourage therapy for a medical condition with the most cost-effective drug (Step 1), and progresses to another higher-cost, second or third line drug, only if necessary (Step 2). When a Step 2 drug claim is submitted, online pharmacy messages will be sent indicating that a lower-cost, clinically effective option is available and the Step 1 drug name or drug class is provided. Drugs included in this program are usually highly utilized and medical literature or clinical guidelines are available to support the sequential use of drugs.
Provincial Integration Program
The Provincial Integration Program recognizes in real-time when the submitted drug claim is for a medication that is part of a provincially funded program under the provincial formulary or as part of a provincial disease program. This program promotes reimbursement from both public and private drug plans.
Specialty Drug Programs
Some provinces have Specialty Drug Programs that cover the entire therapy costs for diseases requiring expensive drugs. These programs do not require income testing and offer the drugs to all residents in the province. If a plan member tries to fill a script for one of these drugs, our system recognizes and flags the drug as being a part of this program in real-time saving both the plan member and pharmacist time and money.
Hospital Drug Program
Some drugs are primarily given in a hospital setting. These drugs require extensive medical monitoring due to the severity of the condition they treat, complex administration (such as intravenous infusion) or potential safety concerns. The Express Scripts Canada Hospital Drug Program contains a list of those drugs intended to be administered in hospital, and flags them in real-time to prevent them from being covered by private drug plans.
The Dynamic Maintenance Drug Program
Express Scripts Canada’s Dynamic Maintenance Drug Program uses claim history in real-time to dynamically determine whether or not plans will pay for up to 100 days of a plan member’s medications.
Express Scripts Canada maintains contracts with virtually all Canadian pharmacies, including chains and independents. This allows us to reduce costs for insurance carriers, third-party administrators and the public sector by arranging for bulk payment of the pharmacy providers.