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Claims processing and adjudication for insurers

Drug Claims Solutions

Build a program that lets you offer accurate drug claims processing. Take care of adjudication, transmission of information and more.

With our Drug Claims Solutions you can:

Reduce costs for employers' plan members

Take advantage of sophisticated cost-containment features. From the Maintenance Drug Program to a Maximum Allowable Cost feature, select the services your customers need.

Focus on your core business

Automate the adjudication process. Reduce administrative tasks to free up the resources you need to grow your core business.

Improve customer satisfaction

Employers will appreciate streamlined and cost-effective claims processing. Plan members will benefit by getting claims processed at the point-of-sale.


Control drug costs while ensuring the most appropriate therapeutic choices are available. TELUS Health provides access to a wide range of drug formularies, including:

  • Traditional formularies: One of the most common plan designs used by plan sponsors, they’re built to offer comprehensive coverage on prescription by law medications, based on an insurer’s needs.
  • Managed Care formularies: Designed to control costs while ensuring the most appropriate therapeutic choices are available. They provide coverage for a select list, based on clinical and cost-effectiveness. Evidence-based guidelines are used to promote first-line drugs.
  • Provincial Mimics: Copies the provincially managed formularies.

Note: TELUS Health can also design customized formularies.


TELUS Health offers a variety of solutions designed to better manage costs and improve health outcomes:

  • Prior Authorization allows you to manage the use of certain prescription drugs by requiring pre-approval based on defined medical criteria. Access our Prior Authorization Forms.
  • Generic Substitution (regular and mandatory) lets you limit the reimbursement amount for drug claims based on the lowest cost generic drug equivalent. Under mandatory generic substitution this occurs even if the prescriber has indicated “no substitution” on the prescription.
  • The Maintenance Drug Program authorizes longer drug supply to plan members who are taking a medication for an extended period of time (typically three months).
  • The Trial Drug Program allows you to control the quantity dispensed of new drugs for a limited initial period. If their response to the treatment is positive, the plan member can then claim the balance of the prescription.
  • In Step Therapy, the most clinically accepted and cost-effective drug therapy is proposed as the first line therapy. A more costly second line therapy is authorized only if the initial treatment proves ineffective.
  • The Speciality Drug Program ensures that plan members submit their claims to the provincial program before submitting them to a private insurer. It also limits the reimbursement amount for certain drug categories with provincial coverage.
  • Blood Glucose Test Strips (BGTS) limits the total BGTS supply a patient can receive based on the type of diabetes drug therapy the patient is taking.

TELUS Health provides core technology solutions that complement the drug formulary and cost-containment programs selected to help you improve health outcomes:

  • Drug Utilization Review analyzes plan member medications to ensure prescription drugs are being taken appropriately (e.g. drug interactions, therapeutic duplication, refill too soon).
  • Coordination of Benefits allows you to control reimbursements across primary and secondary plans.
  • Co-pay, co-insurance, deductibles and maximum track a plan member’s share of the payment made against a claim. This amount may be fixed (co-pay) or variable (co-insurance). This solution also includes deductible amount and plan reimbursement maximums.
  • Pricing regulates the drug ingredient cost and markup at which certain medications are dispensed, depending on any programs applied by the insurer.
  • Dollar, day and quantity limits track various limits when dispensing medication.

Consider the following additional services:

  • Reporting helps you to understand the key factors that influence the cost and performance of a prescription drug plan.
  • Audit ensures the integrity and compliance of a plan through digital and onsite pharmacy drug claims auditing.

Here’s what Drug Claims can do for you

Build a drug claims plan that suits your needs

Pick the services you require to design a plan tailored to your specific needs. Select from a wide range of solutions, from drug formularies to cost-containment programs, technology solutions, and reporting and audit services.

Simplify claims processing

Benefit from an easy and cost-efficient solution for exchanging information and adjudicating claims in real-time. Streamline communication between pharmacies and insurers.

Business Intelligence

Access interactive reports and data to evolve your strategy

Ready to discover Drug Claims Solutions?

Speak to one of our experts.

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