Drug coverage

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Overview

Drug benefits are an important feature of a comprehensive Group Benefits program. Drugs represent approximately 70% of health care expenses and so effective claims management, controls, and innovative plan designs are the keys to selecting the right drug plan.

Payment options

Manulife offers 3 different models for member reimbursement:

Pay-direct

A plan member can simply present his or her drug card and a valid prescription at virtually any pharmacy in Canada. After entering card and prescription information, the claim is submitted electronically for adjudication. The claim is processed within seconds of the claim being submitted. The pharmacist is then able to confirm whether the drug is covered under the plan, requires prior authorization, and the amount allowed. The plan member only has to pay the balance not covered by the plan.

Provided in partnership with ESI Canada, a pay-direct drug plan offers many additional features that help control costs, manage claims, and support employee health.

Deferred payment

Seen as a cost control measure, deferred payment acts like pay-direct. The member presents his or her drug card to the pharmacist and the claim is adjudicated electronically. Similar to pay-direct, the pharmacy will know within seconds if the drug is eligible or not and the amount the member is eligible for. The pharmacist is notified to collect 100% of the prescription cost and the member is reimbursed directly by cheque or direct deposit.

All adjudication is supported through our partnership with ESI Canada, and deferred payment has all of the same claims management controls that are available for pay-direct.

Claims management features

A number of factors converge to drive up the costs associated with a drug plan:

  • aging population
  • the increased incidence of chronic conditions
  • new high cost drugs ‘blockbuster’ drugs such as biologics
  • high cost drugs receiving approval for multiple chronic conditions
  • government regulatory changes
  • inflation factors and more

Manulife Financial offers a number of plan design and claims management features to help control costs without compromising the health and safety of plan members.

Claims Management: Coordination of Benefits

Checking for spousal coverage ensures that both the plan sponsor and the plan member maximize the coverage available and control plan costs.

Claims Management: Drug substitution

Adding generic substitution to a drug plan is an effective way of controlling claims costs.

Claims Management: Dispensing fees and markups

Manulife and Express Scripts Canada® establish and manage both the dispensing fee and mark-up limits.

Claims Management: Drug plan management

Prescription drug coverage is one of the key features of your clients’ benefits plan. You can help your clients keep their plans sustainable.

Marketing material

ESC Pharmacy – Plan Sponsor brochure

Plan sponsor materials

Dispensing Fees Program - Client Brochure (GC2626E)

Mandatory Generic Substitution - Client Brochure (GC2628E)