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Plan Management Features

Our plan management features can be implemented with any formulary option and provide up to 20% savings on your overall drug plan spend.

Our team can take you through each feature and its ability to balance claims and costs.

Formulary Options

Your drug plan starts with the formulary.

At Medavie Blue Cross, we offer several formulary options to help accommodate each plan sponsor’s unique requirements.

Outlined below are 3 of our core formulary options - which option is the best fit for your organization?

What is a Formulary?

A formulary is a defined list of drugs (generic and brand-name) and products covered by a health plan. Depending on the formulary you choose, only drugs that meet the Medavie Blue Cross definition of an eligible drug will be listed.

: Standard offering with our new managed plan Rxperience


Managed Go-Forward


Up to 2%
Up to 4%
Specialty high cost drugs
Medication Advisory Panel (MAP) decisions applied to drugs reviewed after the plan effective date Medication Advisory Panel (MAP) decisions applied
Prescription requiring drugs
Essential over-the counter drugs
Products such as diabetic supplies, knee injections and glucose monitoring systems
Ability to add on additional benefit modules such as; vaccines, sexual dysfunction, fertility, or injectable vitamins

Plan Management Features

We help you achieve greater therapeutic and financial value for your plan by better managing costs and providing easy to implement value-based options.

: Standard offering with our new managed plan Rxperience

Based on your philosophy and objectives, we can help guide on efficient cost sharing methods such as; tiered coinsurance, maximums or deductibles that can ensure members are able to access the coverage they need, and plan sponsors get the best value out of the dollars spent on the plan.

We demonstrate responsible drug management to ensure that members have appropriate and safe access while not assisting in the harm and diversion that can result from opioid use. Medavie Blue Cross starts members on short acting, lower concentration first line opioids then progressing, only if required, to long acting, higher concentration second line opioids. This includes:

  • Tamper resistant formulations where applicable, with evidence-based enhancements that are in line with the Canadian Medical Association Journal (CMAJ) best practice guidelines.
  • Managing opioids with high risk potential, but clinical merit through prior authorization
  • Implementing quantity limits
  • Ensuring a Drug Utilization Review (DUR) at Pharmacy point of sale

While the majority of drugs listed on a formulary are processed immediately at the pharmacy counter, drugs that have been defined by our Medication Advisory Panel (MAP) as high cost specialty drugs require that specific criteria be met before reimbursement can be considered.

All of our criteria are developed under the guidance of the health care professionals on our MAP. Our prior authorization team, led by on-staff nurses and health care workers, translate these criteria into practice to support the right drug for the right patient at the right time, including ensuring prescribed drugs are being used for conditions approved by Health Canada.

Each case is managed uniquely, with prior authorization approvals granted for up to one year to allow for reassessment of the patient’s response to therapy. Our criteria may also include approvals with specific limits in alignment with product monograph. This allows reassessment of the patient’s response to therapy by our in-house teams. We are also able to define approval requests by applying specific limits on a member’s authorization record that can include; coinsurance, quantities and dollar maximums.

Members can use the Drug Search function on their Mobile App to confirm if a drug requires prior authorization. In most cases, high cost specialty drugs are aligned with a drug manufacturer sponsored Patient Support Program, and for certain drugs, enrolment in these programs are mandatory. Should a member require a high cost specialty drug, their specialist will directly engage them with these programs, or in the case of oncology a Cancer Care Navigator. Through our Patient First Network the member’s Case Worker and our in-house Special Authorization Unit work together on our member’s behalf to ensure required forms are completed, and a decision, many within 48 hours, is provided to get members to the right treatment in a timely manner.

Choosing a generic drug is an easy way to get the most out of your drug plan. By using generic drugs when available, both plan sponsors and members can reduce medication costs. Lowering total drug costs is key to ensuring plan costs are sustainable over the long-term.

Mandatory Generic Substitution

Even if a prescriber includes a “no substitution” on the prescription, the brand drug will cut-back to the cost of an interchangeable generic drug. The member can choose to obtain the brand drug, but will be responsible for the differential in ingredient costs, plus their member copay. In instances where a medically substantive need to remain on the brand name drug exists, members can apply through our Exception Process.

Generic Substitution

If a prescriber includes a “no substitution” on the prescription, the brand drug will reimburse at the full brand price, otherwise the brand drug will cut back to the cost of the an interchangeable generic drug. In instances when the drug cuts back, the member can choose to obtain the brand drug, but will be responsible for the differential in ingredient costs, plus their member copay.

No Substitution

Regardless of what is indicate on the prescription, the brand drug will reimburse at the full brand price.

This plan management feature takes a similar approach to Mandatory Generic Substitution, with drugs grouped together according to the condition they treat, not their ingredients. The plan will pay a portion of the ingredient cost up to that of a specified reference drug as determined by Medavie Blue Cross. The reference drug is typically the most cost effective drug, that has been approved by Health Canada to treat that condition.

This plan management is available for the following conditions; Gastrointestinal conditions*, High cholesterol, High blood pressure, and Depression.

Our member web page provides reference drug information. Where available, to help ensure the success of this feature, we recommend integrating this approach with our Pharmacy Partners – Preferred Network offering.

*In Quebec, only gastrointestinal treatments have MAC applied.

When selected, this plan management feature ensures that a member tries first line therapies, and typically lower-cost drugs, before reimbursing for more costly alternatives with the same therapeutic category within a wide variety of conditions such as; Asthma/COPD, Cardiovascular, ADHD and Diabetes.

Unlike a paper prior authorization process, this feature uses our conditional benefit technology. When a claim is processed at the pharmacy, our system will look in the patient's history to see if there has been a claim paid for the first-line therapy drugs. If there has, the claim will reimburse. If the system determines the member has not met the required criteria, the drug will be ineligible for reimbursement.

If a plan has added this feature, even before going to the pharmacy, members can use the Drug Search function on their Mobile App to confirm if a drug will be eligible. If the member has met the criteria, the drug will show as eligible. If they have not met the criteria, the drug will show as not eligible, and comparable first line drugs that are eligible are noted so that members can have these discussions with their Healthcare Professional or Pharmacist.

RX Choices is a unique plan management feature that separates eligible drugs into two tiers with the coinsurance varying amongst the tier. While typical tiered plan designs penalize members by charging a higher copay if they require a Tier 2 drug, regardless of the circumstances facing the plan member and even when they have tried and proven ineffective on first line therapy products, Medavie Blue Cross has designed a more member-centric automated solution. Conditional Copay checks the member’s drug history at the pharmacy counter, to see if first line tier 1 drugs have been tried. If they have, the adjudication system will reimburse that member their tier 2 at their tier 1 coinsurance. If the system does not find the required tier 1 drugs in the member’s history, the tier 2 drug will still be dispensed, and will reimburse at the member’s tier 2 coinsurance.

For plans that have this plan management feature, members can use the Drug Search function on their Mobile App to confirm which tier a drug is on. In instances where a drug is listed as tier 2, comparable tier 1 drugs will be noted so that members can have these discussions with their Healthcare Professional or Pharmacist.

Leveraging our strong pharmacy and client relationships, our Pharmacy Partner - Preferred Network1 options ensure value for the plan sponsor and plan member. Plan sponsors can choose between two savings models: one focused on delivering direct out-of-pocket savings to members, the other directing savings to the overall plan.

We have negotiated special pricing and services that will add new value to your drug benefit plan. Our Healthy Savings website provides detailed information for your members including; participating partners, pharmacies closest to them, and how to access additional member benefits.

1 Preferred Pharmacy Network not available in Quebec.