Pacific Blue Cross automates prior approvals for depression, diabetes, and asthma/COPD drugs in Blue RX managed formulary

Monday, Jun 1, 2020

This new functionality reduces paperwork and gives members immediate access to the medication they need, at the right dose, when they need it.

Appropriate therapies

To ensure the appropriate use of medications for a given condition, Pacific Blue Cross requires coverage approval for some drugs in our Blue RX formulary. Our prior approval process encourages prescribers to consider evidence-based and widely recognized first line therapies as a starting point for treatment.

If a second- or third-line therapy is warranted, our system will now review a member’s claim history and automatically approve the claim if the drug’s eligibility requirements are met. This eliminates the need for a physician to apply for prior approval and the member to wait for adjudication of the claim.

This approach is supported by analysis done by the Patented Medicine Prices Review Board of Canada looking at all new patented medicines that came to market between 2010 and 2017. They found that a staggering number—82%—offered slight to no improvement over existing therapies.


What is Blue RX?

Blue RX is a customized drug plan based on a managed formulary, covering prescription drugs that offer cost-effective treatment for most conditions without compromising health—with a focus on first line therapies.

There are often a variety of treatment options available for a given condition that result in similar health outcomes. All drugs included in the Blue RX formulary are reviewed by in-house and external experts to assess safety and effectiveness, as well the ability to provide cost effective treatment. It excludes drugs with significant safety concerns or drugs that don’t provide additional therapeutic benefits over less expensive options that do the same thing.


Ensuring plan sustainability

Pacific Blue Cross is a strong, active steward of the benefits and plans we administer, pursuing opportunities to manage costs and ensure plan sustainability on behalf of our clients and members. Our unique approach to containing drug costs demonstrated significant savings in our book of business in 2019:


  • up to $22 million avoided by aligning with BC PharmaCare’s Biosimilars Initiative,
  • almost $10 million in direct plan and member out-of-pocket savings due to our Pharmacy Agreement by limiting mark-ups that are charged on drugs, and
  • over $8 million avoided by integrating with over 10 different publicly funded drug programs.

We also increased the number of members using our Blue RX formulary by 9% in 2019.

Analysis of results for specialty drug spend in our BlueRx formulary from an independent consultant was 45.8% lower than their national benchmark in 2018. As plan sponsors grapple with rapidly increasing drug costs for the people they provide coverage for, our drug management practices can lower costs. 

Automated approvals will be applied to drugs that treat depression, diabetes, and asthma/chronic obstructive pulmonary disease (COPD). We are examining our ability to expand the functionality to other conditions where prior approvals are required.

Note that our BlueRx formulary also integrates fully with the BC Fair PharmaCare Special Authority Program. We have worked with the Ministry of Health to access their coverage decisions in real time, further supporting our members in getting the drugs they need as quickly as possible.