British Columbia PharmaCare has partnered with Pacific Blue Cross to introduce new claims technology that aims to improve the process for plan members seeking approvals for coverage of higher-cost drugs only partially covered by the provincial health-care system.
To be eligible for drugs that require special authority under the province’s public drug program, plan members need to meet certain medical criteria, says Leza Muir, senior vice-president and chief operating officer at Pacific Blue Cross. “For those drugs only — and generally they’re the higher-cost drugs — the doctor must fill out a special authority request and send it into PharmaCare for approval.
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“The PharmaCare unit will then review the information that is being submitted and will either approve or deny the drug. And they will generally send their decision back to the physician who sent in that request. . . . The member would have had to either go back to the physician to get a copy of that special authority letter or phone the B.C. government to get a copy of the approval themselves. Then they would have had to send that into their insurer to get that paid.”
The change will streamline the process so that members will no longer have to submit B.C. PharmaCare paperwork to Pacific Blue Cross. “We are able to know, when we’re getting a drug claim, whether that claim has been approved for special authority through PharmaCare already, which would mean a member would not have to do a number of manual steps to send in that special authority request to us to be covered,” says Muir.
According to a press release, B.C. PharmaCare processes about 250,000 special authority requests annually from physicians on behalf of their patients. In 2016, Pacific Blue Cross processed more than 14,000 special authority confirmations.
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The new process should lower benefit costs for plan sponsors and employees who might have out-of-pocket costs for some portion of their employer’s drug plan, says Muir.
“Obviously, from the member point of view, they have improved access to those drugs in a much more timely basis. From a pharmacy point of view, they’re actually able to serve the member when they are at the counter and be able to help them faster. And from a plan sponsor point of view, those that have a tie-in with PharmaCare completely or expect us to fully integrate with the plan, it actually will save the plan sponsor some money in terms of the drug plan spend cost, because we’re sure the drug is being fully integrated with PharmaCare.”
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