Online Adjudicators

Online adjudicators are sometimes used as the intermediary between pharmacies and insurance companies. When a claim is put through at the pharmacy, the information is sent to the adjudicator on behalf of the patient’s particular insurance company.

The online adjudicator works as a tertiary group that puts in place all of the allocations and limitation of the insurance company for that particular patient. Online adjudicators are responsible for validating the pharmacy that the claim is coming from, checking patient eligibility and program eligibility with the insurance company (i.e. is the DIN a benefit), and determining how much of the drug cost, if any, is covered based on the patients plan parameters (how much is taken off the deductible, if it’s a co-pay, etc.).

For example, a patient with an insurance plan through Great West Life will have the claim processed by the online adjudicator TELUS Health Assure Claims  on behalf of Great West Life, not by Great West Life directly . Not all insurance companies use a separate company for online adjudication because they have their own adjudicating system, for example Blue Cross. But for insurance companies that do, they work together with the online adjudication organization, which is why there are often two organizations associated with the same patient plan.

TELUS Health Assure

Assure-TELUS Health Pharmacy Manual

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TELUS Health Assure is the online adjudicator for the following insurance providers:

  • PSHCP
  • Great West Life
  • Sun Life
  • Standard Life
  • And many more

Additional support can be found at the pharmacists section of the TELUS health website here

Express Scripts Canada

Express Scripts Pharmacy Provider Manual

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Express Scripts Canada is the online adjudicator for the following insurance providers:

  • NIHB
  • Manulife Financial
  • GMS (group Medical services)
  • GMS Insurance Inc.
  • Empire Life
  • And many more

Additional support can be found in the Health Care providers portal on the Express Scripts website here

Express Scripts Fall Newsletter 2017.pdf

In this issue:

  • Revised Information on Pharmacist Prescribing
  • No Substitution on Medications
  • Maintenance Drugs Updates
  • Coordination of Benefits

This document is only available to Association members.

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In-Service Pharm Newsletter Fall 2016 (Rest of Canada).pdf

In this issue: 

  • Maintenance Days’ Supplies and Fill Limits
  • Manulife Step Therapy for Diabetes Program
  • The Step Therapy Program and other programs currently
  • Reversals or Adjustments
  • Completing the Pharmacy Provider Modification Form
  • Coordination of Benefits Guidelines Reminders
  • MW or MY Rejections
  • Transmission of Claims for Compounds

 

 

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Express Scripts Fall Newsletter 2015

This issue contains:

  • Claims over $9999.99
  • Process for submitting methadone/suboxone claims
  • Empire life
  • Deferred payment card
  • MW or MY rejections

This document is only available to Association members.

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Provider Connect

Pharmacy Claims Manual

This document is only available to Association members.

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ProviderConnect is the online adjudicator for the following insurance providers:

  • Green shield Canada
  • SSQ

Additional support can be found at the pharmacy provider portal ProviderConnect website here

Medavie Blue Cross

Blue Cross Medavie Pharmacy Guide

This document is only available to Association members.

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Medavie Blue cross is the adjudicator for the majority of federal plans:

  • Canadian Armed forces
  • RCMP
  • Veterans Affairs Canada
  • IRCC (refugees under the IFHP)
  • Medavie Blue Cross

Additional support can be found at the health professionals section of the Medavie blue cross website here

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