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A general term applied to licensed insurance and financial advisors who may specialize in one or more of financial planning, individual, or group insurance/employee benefits. An advisor offers professional advice and guidance to their clients and are compensated on either a commission or on a fee for service basis.
A set of definitions and protocols for building and integrating application software. An API is a software intermediary that allows two applications to transfer information between them.
An individual licensed by a provincial licensing authority in Canada to advise on and sell group insurance products offered by insurers or other organizations offering products or services related to group insurance programs. Compensation is usually fee for service based.
The percentage of eligible expenses that will be paid to a plan member when they submit a claim.
The percentage of eligible expenses that a plan member is required to pay.
The dollar amount of an eligible expense that a plan member is required to pay out-of-pocket.
A spouse or a dependent child who is attending school and who relies on the primary plan member for financial support. To claim under a group plan, all eligible dependents must be enrolled in the group plan.
This is a website that provides healthcare professionals with information and resources about federal drug programs, reimbursement means for unfunded drugs, and patient support programs (PSPs). Other resources include insurance prior authorization claim forms, information on genomic testing for cancer patients, and the role of Drug Access Navigators (DANs).
Also known as Drug Access Facilitators or Medication Reimbursement Specialists, Drug Access Navigators (DANs) are drug access experts that come from diverse professional backgrounds including pharmacy assistants, pharmacists, nurses, and social workers. A pharmacist or social worker may do the role of the DAN even by a different title.
You can find more information under the Stakeholders in the prior authorization process and Resources section of this site.
Drug Identification Numbers (DINs) are an 8 digit number assigned to drugs by Health Canada. It is a unique number that uniquely identifies product characteristics including the manufacturer, product name, active ingredients, strength, and administration. DINs can be found on the label of prescription and over the counter medication.
The Drug Product Database can can be used to determine the drug identification number (DIN) that has been assigned to a drug using a variety of search criteria including drug name and manufacturer. You can find out more about Drug Identification Numbers in the Resources section of this site.
A process by which prior authorization claim documentation is completed online and submitted to payers (insurers, pharmacy benefit managers [PBMs], or public drug plans) electronically according to criteria established by payers. The process is frequently facilitated by a patient advocate in the form of a drug access navigator (DAN) or patient support program (PSP).
In a fully ePA environment at least some claims will be reviewed and approved/declined without any manual intervention. You can find out more about ePA here.
Group benefit plans are a collection of insurance coverages usually provided under one insurance policy that typically include life, extended health (including prescription drugs), dental care, and disability coverage. Plan members insured under the policy are usually employees, but they can also be members of professional associations, organized labour, trusteed plan, alumni or student groups. The policyholder is the group or association who designs and arranges the plan, is a signatory to the contract with the insurer, reports eligible plan members to the insurer, and is responsible for remitting premium payments.
Administration of a drug under the skin and into the bloodstream.
For the purposes of group benefits, an insurer is an organization that is governed by the Insurance Companies Act. They take on the risk for claims under the terms of the contract with the plan sponsor, are responsible for setting premium rates, contract terms, premium collection, administration, claims payment to plan members and their dependents. An insurer is often referred to as a payer because of their role in claims payment. Most insurers have an agreement with a pharmacy benefit manager (PBM) to pay drug claims electronically.
An individual licensed by a provincial licensing authority in Canada to advise on and sell employee benefits/group insurance products provided by insurers or another third party. Compensation is usually commission based.
A prescription drug that has been prescribed for treatment of a disease or condition that has not been approved by Health Canada.
A not-for-profit organization that provides advocacy, advice, assistance, and resources to the public and patients diagnosed with a disease. You can find a list of some patient groups under the Resources page of this site.
A service that patients are usually referred to by their physician for assistance in the claims process for specialty drugs that require prior authorization. PSPs are typically paid by pharmaceutical companies to assist patients with claims and reimbursement for the drug(s) they have been prescribed, including exploring funding from private and public sources. You can find more information on PSPs under the Resources page of this site.
An insurer or pharmacy benefit manager (PBM) who makes reimbursement decisions based on the claims information submitted for a non-specialty and often a specialty drug. PBMs most often provide advice and assistance to insurers on how to manage claims for prior authorization drugs and may administer all or some of the insurer’s prior authorization program, particularly for medium and small insurers.
Companies that are hired by insurers to administer real time online, claims adjudication, mostly for non-specialty prescription drugs, to community pharmacy. The drug identification number for each drug prescribed is compared to the list of eligible drugs electronically in real time and the pharmacist is informed through their online system whether the drug is on the approved list of prescription drugs or if it is not eligible. The system will also inform the pharmacist in real time how much the insurer will pay based on the group insurance policy, including any co-pays or deductibles the patient is required to pay.
When an insurer decides that a prescription drug is subject to the prior or special authorization claims process then the claim must be submitted for approval manually. The review and approval process is manual and may be administered by a PBM on behalf of an insurer.
The person or company (third party administrator), selected by the employer, to manage its benefits plan(s) and communicate with their insurer. The plan administrator’s tasks and responsibilities include communicating with the insurer to add and remove plan members, update salary and plan member dependent information, overseeing beneficiary designations, record keeping, billings and more.
This refers to the highest amount the plan will reimburse annually or within the plan members lifetime for prescription drugs, as well as some other health and dental services. Most small to mid-sized plan sponsors have one or more maximums in place for non-drug related expenses. However, that trend is changing, and prescription drug annual maximums are becoming more commonplace. When they are in place, drug plan maximums are used to reduce the risk of high fluctuations in claims year over year, and hence large increases in premiums.
An individual enrolled in a group insurance plan. The plan member may also refer to an insured dependent spouse or child(ren).
An association, company, partnership, trusteed group/union who is signatory to the contract for a group insurance plan that typically includes coverage for prescription drugs.
A process by which private payers (insurers or pharmacy benefit managers) reimburse a prescribed medication on the condition of satisfactory medical evidence (in the form of a written claim and supporting medical evidence) that is submitted by a patient and their physician according to criteria established by payers. The claim is typically submitted to the payer by mail or fax. The preparation and submission of the claim is frequently facilitated by a drug access navigator (DAN) or patient support program (PSP).
The process of payment for an eligible expense under the group insurance contract, in this case prescription drug(s), by a payer, when satisfactory claims documentation and medical information has been submitted to them.
SADIE is a portal used to submit electronic requests to the Ontario Drug Benefit (ODB) Program’s Exceptional Access Program (EAP), and to track decisions to the requests.
Specialty drugs are a designation of medications that are usually high-cost (typically >$10,000), and often require special handling or administration. They are typically used in the treatment of more complex conditions including cancer, rheumatoid arthritis, Crohn’s disease, multiple sclerosis, and other diseases. Specialty drugs are usually subject to prior authorization under both group insurance and provincial special access programs.
A pharmacy that dispenses medications used to treat rare or complex diseases that either may be subject to prior authorization or may not be in stock at a community pharmacy. Medications subject to prior authorization may have short expiry dates, be required to be stored in a temperature-controlled environment or may need to be administered by a medical professional in an infusion center.
Patients who are prescribed the medications dispensed by a specialty pharmacy have usually been diagnosed with a disease that requires more complex treatment therapies. Specialty pharmacies also provide services that include treatment assessment, patient monitoring, frequent communication with patient caregiver and healthcare provider (HCP). Infusion centres are also available at some locations. You can find a list of some prominent specialty pharmacies under the Resources page of this site.
The Simplify Prior Authorization initiative is an advocate for education about prior authorization (PA) and improvement in current prior authorization practices and processes. If your organization is interested in finding out more, getting involved, or in sponsorship of this important initiative, please contact us via the link below.
