ClaimSecure - ClinicalServices

By: ClaimSecure  09-12-2011

ClaimSecure’s experienced Clinical team develops, maintains, and refines customized formularies, while complying with the rules and regulations of each provincial prescription drug program. Our licensed pharmacists, dentists and physician consultants will work closely with our clients to develop flexible cost-effective strategies that meet our clients' specific needs. Our services are competitively priced and our clients consistently rate our Clinical services extremely favourably in terms of client satisfaction, and return on investment.

Drug Utilization Review (DUR)

Drug Utilization Review has become an important tool that is used by many clients to effectively manage the costs of their health benefit plans. Our retrospective DUR program consists of reports and analyses focusing on the utilization of the top therapeutic categories and drugs. It also includes clinical recommendations leading to cost-savings and improved patient outcomes by eliminating unnecessary drug therapies, promoting more cost-effective drug prescribing and avoiding healthcare expenses associated with inappropriate drug use.

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 pharmacists and physicians review drugs and therapies on a continuous basis to develop and maintain our managed formularies.

Formulary Management is based on a stepwise approach to therapy. This ensures that higher cost drugs are reserved for second line therapy after the prior therapy has proven unsuccessful. High utilization or potential off-label use drugs are included in this approach. All new drugs are evaluated monthly, based on their use (indication), efficacy, safety, cost and value to the client. These factors are equally important in determining whether to add a drug to a plan’s formulary as a fully covered benefit, or a benefit requiring Special Authorization (see below).

ClaimSecure has a proven track record of reducing our clients’ drug costs using managed formularies. For optimal results, we recommend utilizing formulary management combined with Special Authorization and ongoing communication with plan members. This approach allows plan sponsors to substantially mitigate the impact of drug cost increases on their prescription drug health benefit plan.

Special Authorization

Drugs required to be reimbursed through the Special Authorization process typically either have a higher cost than therapies currently covered under a plan’s existing formulary, or have the potential for inappropriate use (unapproved condition). To obtain 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. Upon receipt of a completed Special Authorization request form and supporting documentation from the plan member’s prescribing physician, ClaimSecure’s clinical staff members evaluate the request to determine whether coverage is approved. Members who meet the approval criteria will receive the medication they require. This process reduces drug benefit costs while ensuring that members receive the most appropriate and cost effective drug therapies.

For a current list of Special Authorization Drugs and Approval Guidelines

Specialty Drug Program

The Specialty Drug Program is a type of managed formulary, designed to manage only specialty or high-cost drugs (i.e. those drugs with an expected annual cost of $10,000 or more). With escalating drug costs, the management of specialty drugs is critical for preserving the financial integrity of the client’s health benefit plan. The Specialty Drug Program is a risk management solution and an enhancement to existing Stop Loss programs. Member’s access to specialty drugs is subject to the Special Authorization process. This ensures the use of less expensive therapeutic alternatives first, and the coordination with available government programs, resulting in the optimal use of drug benefit dollars.

PharmaCare Coordination Program

The PharmaCare Coordination program provides plan sponsors with a significant savings opportunity by notifying members who have reached their maximum claims threshold to register with their provincially funded drug programs where available.

Health Education

ClaimSecure’s health education programs are flexible and can be tailored to meet a client’s specific needs. The education program can take the form of live or web-based seminars or the general distribution of information on a particular disease state. The program’s objective is to provide relevant health information to members, individualized follow-up care when appropriate, and the measurement of member health outcomes.

In addition, with the assistance of selected healthcare industry stakeholders and participants, ClaimSecure has developed a series of health information and disease intervention programs. Please see our


Pharmaceutical Strategies

ClaimSecure’s Clinical team offers competitive consulting and reporting services dealing with drug access and healthcare issues. Composed of highly skilled professionals with diverse backgrounds and areas of expertise, the ClaimSecure Clinical team provides the pharmaceutical industry with value added information and services such as:

  • Drug coverage analysis - ClaimSecure provides a Post-Submission Summary Report for each new drug evaluated, as well as coverage analysis of a therapeutic class. This service clearly communicates various complex plan designs, and provides accurate drug coverage information.
  • ClaimSecure maintains extensive claims and eligibility databases, which are utilized to assess patient demographics, study regional claiming breakdowns, and prepare longitudinal patient trending analyses and budget impact analyses.

The information in this article was current at 06 Dec 2011

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