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Pharmacy Benefit Manager

Our Advantages

We deliver personalized solutions based on your organizations’ specific needs that ensure your members receive the right treatment at the right time and at the right price.

Exclusively available by Medavie Blue Cross.

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%

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.

Exclusively available by Medavie Blue Cross.

Point of Service (POS)

Our real-time transaction adjudication system helps members experience better medication adherence that results in effective treatment with the desired health outcomes. Built into the system are the following technology features:

Many provincial governments have specialized health and drug programs that provide eligible residents with full coverage for medications that treat certain conditions such as; Cystic Fibrosis, Multiple Sclerosis, Cancer and HIV/AIDS, as well as products and services for items such as insulin pumps, and diabetic supplies. Since the majority of these claims automatically adjudicate between our system, and another pharmacy system, we ensure the system alerts pharmacists when a government program is available or when a drug should be administered in-hospital. When Medavie Blue Cross is the secondary payor, our system ensures that plans and members do not pay more than what they would have paid had we been the first payor, and all practices align with Canadian Life and Health Insurance Association (CLHIA) guidelines.

In the provinces that provide Pharmacare programs, our system is set-up with trigger limits unique to the respective Pharmacare program. If a member has not provided proof of registration and hits our minimum limit, our system will send communication to remind them to enrol in their respective provincial program. A maximum trigger limit is also set so that if the member still hasn’t registered, the system will turn off claims payment until we have received confirmation of registration thereby protecting the plan from unnecessary costs.

Originally introduced in 2004, this feature uses the member’s claim history to confirm they have met the required criteria, all while still at the pharmacy counter, thus eliminating the need for the member to submit a paper form for assessment. As the drug landscape has continued to evolve, so too has the way we use this technology. Where our Medication Advisory Panel (MAP) may have in the past recommended to not list a drug when lower cost alternatives are available; we can now leverage this technology to allow for a larger list of eligible drugs to be available for the niche patient population who would benefit.

Medavie Blue Cross was the first carrier to implement an automated member-centric solution for plans with our tiered coinsurance product Rx Choices. Typical tiered plan designs penalize these members by charging the higher copay even if the member has already tried and failed on the tier 1 drug(s). This feature will reimburse a member’s tier 2 drug at the tier 1 co-pay if the system confirms that the member’s drug history reflects that they have claimed the required tier 1 drug(s) previously.

To ensure that a member is only provided with a specific quantity our system can provide a specific quantity of a drug or product based on the member’s claim history for their specific needs.

Blood Glucose Test Strips
Our system determines a member’s annual limit of blood glucose test strips based on the diabetes treatment they are receiving. This approach is based on best evidence, and in alignment with several government-sponsored health programs in Canada. The new limits are automated right at the pharmacy counter and also ensure that those who need test strips to manage their disease will continue to have access to them.

Medavie Mobile App

We support members with easy plan access on the go and provide them with the resources and tools they require.

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

National Network

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.

Partnerships with Drug Manufacturers

As the first insurer to negotiate a product listing agreement Medavie Blue Cross remains an industry leader in negotiating directly with drug manufacturers on behalf of our clients across Canada to improve cost-effectiveness of new or existing drugs, to address the cost-effectiveness of new or existing drugs; increase access to care; and contribute to the affordability of private plans. Our in-house team has negotiated more than 50 high-volume chronic medications and high-cost specialty drugs, across a wide range of health conditions. This diversified portfolio approach is generating sustained reductions in cost, and creating head room for plans to make new, innovative drugs available to members who need them.

As a result of our direct relationships with Drug Manufacturers we were able to successfully implement our Patient First Network. Our enhanced specialty high cost drug case management program not only provides Patient Support Programs and Oncology Navigators with priority bar coding, telephonic confirmations, and direct access into our Special Authorization Unit, but it provided us the opportunity to provide a direct service that ensures members do not have to navigate this process on their own, and we didn’t have to engage a third party that would have increased costs to our plan sponsors.

Partnerships with Pharmacies

Medavie Blue Cross has signed agreements with each chain, banner and individual pharmacy in Canada. These agreements lower drug costs and, in many cases, enable member access to enhanced medication support services. Our pharmacy agreements are automated within POS system, to consistently apply limits, caps on mark-ups and dispensing fees. Balance billing clauses (varies by province) protect members from excess out-of-pocket costs, and audit rights and additional controls protect the plan. With respect to high cost specialty drugs, we negotiated directly with pharmacies and created a network of “willing providers” who adopted our competitive specialty pharmacy agreement that not only protected plans but also ensured members were able to retain their choice of pharmacy.

Our direct relationships with pharmacy helped us in the development of our Days’ Supply program. Our system reviews the claim history of the individual and prompts the pharmacy to dispense the appropriate day’s supply based on established use of the drug by the specific member. If the quantity of the drug is dispensed incorrectly, the pharmacy will be prompted to match the recommended day’s supply.

In this era of online purchasing and COVID-19, plan members more than ever are looking for options to have maintenance medications delivered directly to them. Our direct relationships with Sobeys and Alliance pharmacies provided us the unique opportunity to launch MyHomeRx to all Medavie Blue Cross members (except in Quebec), that not only provides a home delivery option, but competitive dispensing fees.

Partnerships with Providers

Medavie Blue Cross has a comprehensive network of pharmacy and extended health care providers across Canada to provide service to their regionally dispersed clients. We have a dedicated in-house team of professionals with expertise in provider relations services. We continue to leverage our existing relationships to build, foster and expand our interactions with individual providers, provider groups and associations. Our team will also engage new providers across Canada where existing relationships do not currently exist.

The Canadian Association of Blue Cross Plans represents the independent Blue Cross member plans operating in regions across the country. From sharing our expertise from our respective regions on plan management features, or understanding available government sponsored programs, to collaborating on joint initiatives like product listing agreements or Blue Advantage these partnerships allow us to provide additional valuable savings to plan sponsors and services to our members across Canada.

Exclusively available by Medavie Blue Cross.

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.

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.

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.

Exclusively available by Medavie Blue Cross.

Diabetes, obesity, heart disease, mental health – treating these rapidly growing chronic diseases includes more than just medications. Our wellness strategies, like our Managing Chronic Disease benefit – the first of its kind in Canada, allows members access to leading treatment and devices.

Our proprietary Patient First Network integrates member enrolment in support programs, coordinates with cancer-care case managers and navigates to pharmacy – allowing your members to concentrate on their health and recovery.

Our Mental Health Practitioners Benefit goes beyond prescription drugs and allows members access to expanded mental health care practitioners for easy and personalized help and resources. This includes early psychiatric evaluation.

Our online Cognitive Behavioural Therapy (iCBT) product provides convenient virtual treatment with accredited therapists for counselling and education services.

Our virtually accessible Personalized Medicine service helps members know how their DNA will affect response to specific drugs which helps their doctors prescribe them the most effective and safe medication, at the right dosage. Our virtual services can be accessed on our Connected Care platform directly through the benefit plan or individually by our members on a per usage fee or subscription module basis.