Equitus Consulting Inc.
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RESOLVE

As the cost of drugs continues to climb and as more drugs costing $20,000 come to market, plan sponsors are faced with the question of covering or not covering them.

RESOLVE Pre-authorization allows plans to cover these medications while ensuring that it is appropriate for the plan to pay for them for the particular member, or dependent making the claim.

RESOLVE works by:

Evaluating all new drugs that come to market and determines which should require pre-authorization. It does this by examining five factors:

  • Impact on quality of life
  • Length of time the patient will be taking the drug
  • The place in therapy of the medication i.e. is it a first, second or third line therapy
  • The likelihood that the drug will be used off-label
  • The cost of the medication

Having the patient’s physician complete a detailed questionnaire detailing diagnosis, other medications that have been prescribed, test results etc.

Using a Medical Review Officer (MRO) to determine whether or not it is appropriate that the patient’s plan pay for the medication in question. An MRO is a fully qualified physician who has received additional training and is a recognized by the Medical Review Officer Certification Council (MROCC)

– In the event that a patient is declined coverage and wishes to appeal, the resolution is arrived at between the MRO and the patient’s physician.

What are the advantages to a plan sponsor?

The three main advantages are:

  • The plan sponsor is assured that plan members receive the medication they require while the plan is protected from undue and/or inappropriate utilization
  • The plan sponsor is not part of the decision making. RESOLVE is independent of the plan sponsor and the insurer and the union, if one is involved.
  • Decisions are rendered very quickly, usually within 48 hours of RESOVE receiving the complete information from the patient’s physician

How can I learn more about RESOLVE?
Simply call Anna Smith at 905-847-8323 extension 222 or toll-free at 1-866-401-8323