Exclusively available by Medavie Blue Cross.
Medication Advisory Panel (MAP)
Development of our drug plan management strategies are based upon rigorous application of expert clinical and economic evaluation of all new medications to market by our Medication Advisory Panel (MAP).
Leveraging the clinical expertise of our in-house panel that includes; General Practitioners, Pharmacists, Pharmacoeconomist, Nurses, Actuarial Analysts, and Product Specialists on a monthly basis to determine which drugs have clinical merit & cost effectiveness.
Our expert reviews inform the development of our formularies, as well as prior authorization criteria, specialty drug case management protocols and price (PLA) negotiation leverage, foundational elements to evidence-based drug plan management.
Number of Drug Submissions to Medavie Blue Cross, 2019
Cancer 44% | Auto Immune 8% | Anti-viral HIV 5% | ADHD 2% | Eye 5% | Rare Genetic Disorder 8% | Diabetes 2% | Other 26%
Patient First Network
Our Patient First Network takes a unique approach to caring for our members. As the industry’s only nurse-managed specialty high cost drug case management program, our in-house team delivers priority prior authorization reviews with decisions often within 48 hours.
Early in the treatment selection process, our teams coordinate directly with case workers - including Patient Support Programs (PSPs), Oncology Drug Navigators, Specialists and Specialty Drug Pharmacies – to accelerate the assessment and approval of the optimal specialty drug. When not already enrolled, our Member Experience Specialists (MES) work directly with members to help navigate them to these beneficial programs.
Unlike other carrier programs, there is no additional cost to plan sponsors and no third party control (or conflict) with network. Outside Quebec, with our open specialty network of “willing providers” members retain their choice of pharmacy, while plan costs are protected through our negotiated pharmacy agreements including caps.
Medavie Mobile App
We support members with easy plan access on the go and provide them with the resources and tools they require.
Medication Adherence Support
Taking medication as prescribed is easier said than done! It’s simple to miss or skip a dose, or to take it at the wrong time of day. Using our mobile app, members can create reminders on when to take medications, when to refill prescriptions to ensure medications are taken as prescribed.
The Drug Search function in our mobile app provides important drug information based upon the member’s actual formulary. Key features include:
- Confirming drug eligibility, including comparable drugs in case the specific drug is not eligible on the formulary
- Requirement for Prior Authorization
- Availability of a Government program
- Tier information for plans with Rx Choices™ - our tiered coinsurance plan management feature
We invest in strong manufacturer, pharmacy and provider relationships to drive quality and optimal plan spend.
Our dedicated pharmaceutical partnership strategy focuses on building business to business relationships with pharmaceutical industry stakeholders. We target the appropriate use and cost of drugs, to ensure plan members have access to innovative drugs at fair prices and to valuable support services all while ensuring plans remain sustainable. To combat rising costs Medavie Blue Cross has negotiated pharmacy agreements that focus on mark-ups and fees and product listing agreements that focus on the ingredient cost.
In Quebec, along with our product listing agreements, we offer Usual and Customary (U&C) pricing as an add-on plan management feature to help plans save more.
Our partnerships drive greater plan savings and lower member out-of-pocket costs with specially negotiated rates on:
- The ingredient cost or manufacturers list price
- The pharmacy mark-up¹
- The dispensing or professional fee²
1,2 negotiated rated on the pharmacy mark-up and the dispensing or professional fee are not offered in Quebec.
Exclusively available by Medavie Blue Cross.
Drug Utilization Review (DUR)
Our adjudication system’s Drug Utilization Review (DUR) capability validates, monitors and cross checks groupings of drugs within the member’s claims history. Our system has the capability to accept DUR claims with customized messaging to pharmacy with pertinent information of the situation, and to reject DUR claims with override intervention codes where warranted. Product information is regularly updated with files from a third party source. DUR helps pharmacists’ ensure members’ safe and appropriate utilization of drugs.
Our internal investigative Audit team is responsible for identifying abuse and fraud cases. Questionable claims practices are identified and resolved by targeting problematic claims and the service providers involved with such claims. In addition, as health care becomes more complex and as the administration review process becomes more clinical, we seek input from clinical experts to assist us in our assessment and decision process. Random claims review and audits by our investigative services team help detect atypical claims situations. The audits help eliminate waste and manage costs, with proven savings to clients
Our proactive drug pipeline monitoring helps identify early on whether a new drug will present clinical and/or cost issues or opportunities for our plans.
Number of late phase pipeline drugs (IQVIA, 2019)
Cancer 24% | Auto Immune 22% | Cardiovascular 8% | Blood 7% | Eye 7% | Lung 7% | Skin 6% | Gastrointestinal 5% | Diabetes 5% | Infection 5% | Alzheimer's 5%
Our annual trend report provides perspective and insights into strategies, opportunities and practical applications to convert private plan health claims datasets into important insights to optimize the management of health plans.
Group level reporting
By incorporating annual trends with a group's actual data we incorporate the specific plan experience to monitor the overall performance and flag any trends that are outside of the experience compared with Medavie Blue Cross' book of business.
Customized Member Communications
One of the most practical applications of drug claims data is to covert member-level claiming patterns into action. We can provide customized member health-related information based on the personal use of their drug benefits.