Clinical Services for Cost Containment

At ClaimSecure, we’re proud to say our clients rate our clinical services extremely favourably in terms of balancing patient impact and return on investment, and why wouldn’t they? We’re dedicated to client satisfaction, and our services are competitively priced.

Our experienced clinical team develops, maintains, and refines customized formularies, while complying with the rules and regulations of each provincial prescription drug program. What’s more, our licensed pharmacists, dentists and physician consultants work closely with our clients to develop flexible, cost-effective strategies that meet our clients' specific needs.

Ask us how our products and services can help you get more out of your benefit dollars. We welcome the opportunity to talk to you about a customized strategy based on our tried and true approach.

Formulary Management

ClaimSecure offers a complete suite of drug plan designs, including traditional prescription plans, prescribed plans, and government formulary plans. In addition, we offer custom-managed formularies to meet our clients' specific requirements. Our experienced team of pharmacists and physicians review drugs and therapies on a continuous basis to develop and maintain our managed formularies. All new drugs are evaluated monthly, based on their use (indication), efficacy, safety, cost and value to our clients. These factors are equally important in determining the coverage status of the drug.

We offer many formulary management solutions:

  • Managed Formulary

    Managed Formulary is based on a stepwise approach to therapy. This ensures that higher cost drugs with a more cost-effective drug alternative are reserved for second line therapy only after prior therapy has proven unsuccessful. This approach also includes expensive biologics, specialty drugs and potential off-label use drugs, all of which require special authorization to ensure that the right drug is used by the right member for the right indication.

    View current list of Special Authorization Drugs and Approval Guidelines.

    View FAQs on Special Authorization.

  • Managed Formulary Select

    Managed Formulary Select is a tiered formulary that allows both plan sponsors and plan members to save by encouraging the use of lower-cost drug alternatives for select therapeutic classes. Formulary Select drugs are select brand name drugs for which more cost-effective and safe alternatives exist. The cost-effective alternatives are reimbursed at a higher level than their brand-name counterparts, which encourages plan members to choose them. Plan members still have access to the Managed Formulary Select drugs but these are reimbursed at a lower level. Under Formulary Select, members can access the high-cost specialty drugs through the Special Authorization process.

    View current list of Formulary Select Drugs and Available Alternatives.

  • Formulary Protect

    Formulary Protect provides coverage for commonly prescribed drugs while excluding all Specialty Drugs to ensure the sustainability of your drug plan.

    This new plan design is expected to impact a very small number of your members – less than 1%, while eliminating your exposure to high cost Specialty Drugs, which can represent over 20% of your total drug plan cost. Formulary Protect still provides coverage for commonly used drugs while ensuring the sustainability and affordability of your plan.

  • Formulary Protect Plus

    Formulary Protect Plus provides coverage for most commonly prescribed medications while excluding Specialty Drugs funded by the provincial drug programs. It also offers two important benefits to your plan members:

  1. Coverage Navigation Service – Our Clinical Services experts provide specialized assistance and guidance on coverage options to your members for the Specialty Drugs. This service includes introducing members to provincial and manufacturer sponsored programs for coverage and assistance with their application. Your members are supported every step of the way.
  2. Specialty Drugs not listed on the provincial formulary are available if the plan member attempted and failed the therapeutically equivalent Specialty Drug(s) covered by the provincial program. Drug coverage is then based on ClaimSecure’s Special Authorization criteria.

Notes:

  • Formulary Protect and Protect Plus are not available in Quebec.
  • Coverage Navigation Service is available on a fee for service basis and is optional under Formulary Protect and mandatory under Formulary Protect Plus

ClaimSecure has a proven track record of reducing our clients’ drug costs. Our managed formularies support our commitment to a balanced approach in drug plan management, ensuring accessibility of important medications for plan members, while balancing plan sponsors’ needs for sustainable and affordable drug plans.

Special Authorization

Certain drugs can only be reimbursed through a clinical review process referred to as Special Authorization. These drugs are typically high in cost or have the potential for inappropriate use (unapproved condition). To get coverage for these drugs, members must meet the pre-established clinical criteria set out in ClaimSecure’s Special Authorization Drug and Approval Guidelines. Our clinical team supports plan sponsors in setting the approval criteria. Once a completed Special Authorization request form and supporting documentation have been received from the plan member’s prescribing physician, our clinical team evaluates the request. Plan members only receive the medication if approval is granted. This process reduces drug benefit costs while ensuring that members receive the right drugs at the right time.

View current list of Special Authorization Drugs and Approval Guidelines.

View FAQs on Special Authorization.

Specialty Drug Program

ClaimSecure’s Specialty Drug Program is a risk-management solution and an enhancement to existing Stop Loss programs. It is designed to manage only specialty or high-cost biologic drugs - those drugs with an expected annual cost of $10,000 or more. With escalating drug costs, the management of specialty drugs is a critical cost-containment strategy. Members’ access to specialty drugs is subject to the Special Authorization process. This ensures the use of less expensive therapeutic alternatives and coordination with available government programs for optimal use of drug benefit dollars.

View current list of Special Authorization Drugs and Approval Guidelines.

Provincial Coordination Program

The Provincial Coordination Program provides plan sponsors with a significant savings opportunity by ensuring that government funded programs are the first payor, where applicable.

In provinces where a universal PharmaCare Program is available, ClaimSecure advises members who have high drug cost claims to register with their provincial program.

In Ontario, for sponsors whose drug plans have a maximum or exclude certain high-cost medications, ClaimSecure promotes cost containment by helping plan members apply for the Trillium Drug Program. The Trillium Drug Program is intended to be the payer of last resort, helping Ontario residents under the age of 65 with high out-of-pocket drug costs relative to their family income.

View FAQs on the Ontario Trillium Drug Program and the Trillium Coordination program.