For Insurers and Employers

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National Formulary


With millions of Canadians relying on insurance to cover their medications, affordability and availability of quality drug therapies is key. That’s why TELUS Health established the National Formulary – an evolving list of prescription drugs that qualify for insurance coverage – to ensure coverage and accessibility to safe, cost-effective and quality drug therapies.

National Formulary FAQ

 

Plan Design


Created to promote stronger health outcomes, control drug costs, increase accountability for drug therapy and drug plans – formularies are essential to maintaining a sustainable healthcare system in Canada. By offering a wide range of formulary options, TELUS Health allows insurance carriers and plan sponsors to provide adapted coverage for their members’ specific needs.

 

Payment Options


Electronically processing claims right at the pharmacy offers plan sponsors and members alike greater flexibility in managing the submission and adjudication process – and payment plays a big role. To better address the needs of plan members, the TELUS Health Drug Claims Adjudication service allows for the use of multiple payment options.

 

Drug Claims Auditing


Millions of drug claim transactions are processed each year and the accuracy of each one is critical for ensuring the right payment is made at the right time to the right person. That’s why it is important for the adjudication process to contain various audit features that can provide an alert on potential areas of concern and, if needed, identify pharmacies and other providers that require on-site audits. In-house pharmacy reviews may also be performed to ensure the appropriateness and accuracy of payments.

 

Prior Authorization Program for Drug Therapy


Used in conjunction with a formulary, the Prior Authorization Program aims at managing drugs more effectively while allowing plan sponsors to limit the use of certain drugs by requiring patients to obtain a prior authorization before coverage is issued. The targeted drugs – often very expensive or with high potential for misuse, are eligible for reimbursement if the patient clinical criteria are satisfied. The clinical protocols used in the Prior Authorization Program are based on guidelines currently in place for provincial formularies, as well as from independent review sources.

Prior Authorization Forms
Prior Authorization FAQ

 

Reporting and Analytics


Leveraging powerful reporting tools to help insurers underwrite and analyze claims data, the TELUS Health Drug Claims system can show a complete business snapshot. For insurers offering pay-direct and deferred payment processing for drug claims, there are two types of reporting tools available: Online Reporting and Interactive Reporting.

 

Coordination of Benefits


When plan members are covered by more than one drug plan, benefits from both plans can be coordinated at the pharmacy when a prescription is filled for a patient. To do so, plan members need to provide their drug card to the pharmacist, who may then submit both the primary and secondary claim electronically at the point of sale. Once processed, plan members need only pay the remaining amount not covered by the various drug plans.

 

Maintenance Program


The maintenance program allows the pharmacist to dispense longer days’ supply (typically three months) to patients who are taking a medication for a long duration. Promoting longer days’ supply based on specific criteria reduces the number of dispensing fee charges and is often more convenient for the plan member. This program is suitable for patients with a condition that can be safely treated without reassessment for up to 100 days. The maintenance program is not currently offered in Quebec.

 

Drug Utilization Review


A Drug Utilization Review is conducted by TELUS Health in real-time when prescription medications are dispensed to plan members. Each prescription drug is reviewed against a series of criteria, based on the plan member’s medical drug history within the last 100 days, to be sure the prescription drug isn’t being taken inappropriately. Checks are performed against all pharmacies where the plan member has used their drug card.

 

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