Health Case Management Discover the difference one-on-one support has made on health outcomes

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1 Issue 4 Before DrugSolutions was initiated, 90 per cent of our plan sponsors had not made a drug plan design change in over a decade. The impact of DrugSolutions has been undeniable with nearly 95 per cent of our plans adopting one or more of the initiative s options. Our latest update focuses on the real impact of our programs, including many examples showcasing DrugSolutions in action. Health Case Management Discover the difference one-on-one support has made on health outcomes Pharmacy Network Value Plan See how filling prescriptions at Costco Wholesale pharmacies saves money Acute/Maintenance/Specialty Formulary The benefit of flexible coinsurance levels for each drug category Maintenance Medication Management Lower drug expenses with free programs offered through Shoppers Drug Mart Specialty Drug Developments The impact of the most recent life-changing treatment breakthrough on a drug plan

2 Health Case Management: Making a difference In 2012, Great-West pioneered a program designed to assist plan members who require specialty medications to treat complex, chronic conditions like rheumatoid arthritis and Crohn s disease. Health Case Management (HCM) provides support and education to those who are enrolled. So far, 6,300 plan members have participated in the program. The right treatment for the right patient Health case managers are registered nurses and play a key role in HCM. They support plan members and their physicians and can help identify alternative treatment options, while providing ongoing assistance such as identifying community support programs or patient assistance programs. On average, two plan members were assigned a health case manager every day in ,000 PRESCRIPTIONS WERE FILLED BY PLAN MEMBERS WHO PARTICIPATED IN THE DESIGNATED PHARMACY PROGRAM IN There are over 2,000 pharmacies in the HealthForward designated pharmacy network across Canada including: Traditional chains like Shoppers Drug Mart and Lawtons Drugs Grocery channels including Safeway and Loblaws Independent pharmacies 1 74 % 84 % Outstanding program results: 74 per cent 1 of participants indicated that HCM helped them function better in their day-to-day and/or work life 84 per cent 1 of participants strongly agreed that their health case manager was easy to talk to and explained things in a way that was easy to understand The HealthForward designated pharmacy network helps ensure plan members taking certain specialty medications benefit from competitive pricing, and work with pharmacists who have experience with those medications. Medication delivery One of the goals of HCM is to shorten the time it takes from when a plan member is prescribed a medication to the time they begin taking it. Through the program, plan members can arrange for the dispensing and delivery of medications to a treatment location or their home. In 2014, 22 per cent of enrolled HCM plan members used this service.

3 drugsolutions in Action Plan member: Morgan, female, age 26 Diagnosed with rheumatoid arthritis Prescribed a specialty drug priced at $22,000 per year, requiring Prior Authorization Morgan s drug plan covers 80 per cent of drug costs leaving her to pay $4,400 out of pocket Valuable support along the way When Morgan s application for the drug was approved by Great-West, she was assigned a health case manager, Sandy. Sandy advised Morgan of the financial assistance options available for specialty drugs. Since the out-of-pocket cost was unaffordable for Morgan, Sandy helped her enrol in a patient assistance program. Morgan was able to fill her prescription, which was in injectable form. When Sandy followed up with her, Morgan was feeling a little lost. She d selected the home delivery option for her medication, but wasn t sure how to administer the shot to herself and couldn t reach her doctor for instruction. Sandy contacted the doctor s office and was able to help ensure Morgan received the proper injection training. Morgan has openly expressed her gratitude to her health case manager for all her help throughout the process. 1 Great-West Life: Health Case Management Assessment

4 Pharmacy Network Value Plan: Savings in store An enhancement to existing benefit plans; the Pharmacy Network Value Plan (PNVP) provides more coverage or a lower deductible when plan members fill prescriptions at Costco Wholesale pharmacies. Costco s competitive pricing, through a combination of lower dispense fees and overall lower-than-average prescription drug costs, can also help save plan members money on their out-of-pocket costs. A Costco membership is not required to fill prescriptions at their pharmacy. 4,000 plan sponsors AS OF DECEMBER 2014, OVER 4,000 PLAN SPONSORS HAVE INCORPORATED ONE OF OUR PNVP OPTIONS INTO THEIR BENEFITS PLAN. Home delivery Plan members can benefit from the convenience of Costco s free home delivery service: Offered for prescription maintenance medications for conditions such as diabetes, high blood pressure and high cholesterol No charge for 4-7 business day delivery Currently available in Alberta, New Brunswick, Nova Scotia and Ontario ON AVERAGE, GROUPS WHO HAVE ADDED THE PNVP HAVE THREE TIMES MORE PRESCRIPTIONS FILLED AT COSTCO PHARMACIES THAN THOSE WITHOUT A PNVP OPTION. 3

5 drugsolutions in Action Plan sponsor: Lois, hair salon chain owner 85 employees Based in Manitoba Plan sustainability After 10 consecutive years of drug rate increases, some as high as 34 per cent, Lois s advisor introduced the PNVP options as a way to manage costs without cutting back on coverage or increasing employee contributions. Lois chose the improved coinsurance option. Her staff would continue to receive 80 per cent coinsurance if they filled their prescriptions at Costco, and 70 per cent if they purchased their drugs elsewhere. The result was a win-win. Within the first year, Costco usage rose 14 per cent and Lois s renewal rate on drugs decreased by 23.5 per cent! Lois was able to sustain her coverage and save on claim costs, while her employees saw no change in coinsurance when they filled their prescriptions at Costco. Plan sponsor: Geoff, courier company owner 92 employees Based in New Brunswick Extra savings Geoff s advisor noted that nearly 20 per cent of his staff s prescription claims were filled at Costco, which made Geoff s business a good match for the PNVP options. Geoff changed his benefits plan to offer further incentive for his employees to use a Costco Wholesale pharmacy. If staff filled prescriptions at Costco, they would not have to pay the pharmacy s dispense fee. Those who shopped at other pharmacies would have to pay the dispense fee, which is an out-of-pocket cost of $10 (New Brunswick average). To help encourage participation, Geoff distributed an educational factsheet to help staff understand their coverage. As a result, in just a few months over 30 per cent of staff was using Costco to fill their prescriptions. The company saw savings from Costco s low prices and Geoff s employees were able to save out-of-pocket costs. 4

6 Acute/Maintenance/ Specialty Formulary: Variable coverage levels The Acute/Maintenance/Specialty (AMS) formulary provides flexible plan design and comprehensive coverage. By implementing the AMS formulary, plan sponsors can reduce coinsurance levels for lower cost medications, and offer full coverage to those requiring higher cost speciality medications. 50 %+ Coverage for acute medications can be set at a coinsurance level of 50 per cent or higher. Acute medications include antibiotics and pain medications prescribed to treat onetime or short-term conditions. The average annual claim amount for each plan member who submits claims for acute medication is $100. Specialty medication impact LESS THAN ONE PER CENT OF CLAIMS ON GREAT-WEST S BLOCK OF BUSINESS ARE FOR SPECIALTY MEDICATIONS YET THEY ACCOUNT FOR OVER 20 PER CENT OF THE TOTAL AMOUNT PAID. 60 %+ 100 % Coverage for maintenance medications can be set at a coinsurance level of 60 per cent or higher. Maintenance medications are often prescribed to treat chronic or long-term conditions, like high blood pressure and high cholesterol. The average annual claim amount for each plan member who submits claims for maintenance medication is $500. Coverage for specialty medications is set at 100 per cent. Specialty medications are generally prescribed to treat a specific disease state that may be genetic, complex or rare. Treatment commonly requires drugs that have special administration or handling requirements or a high level of patient monitoring and support. Some of these medications treat conditions for which there is no other treatment and have costs that can reach $600,000 annually. With such high pricing, even a coinsurance level of 90 per cent would make treatment unaffordable for most plan members. $$ The protection provided for specialty medications is supported by large claim pooling coverage provided under most insured health benefit plans. It allows the significant cost to a particular plan sponsor to be spread across a larger pool. 5

7 drugsolutions in Action Plan sponsor: Spencer, public service organization manager 400 employees Based in Ontario Coverage where it counts Spencer s drug plan provided 90 per cent coinsurance for all medications, which left 10 per cent for plan members to pay out of pocket. With this coverage, plan member Robin paid $1 for her $10 eye drops, an acute medication. Another plan member, Bill, who needs a specialty drug for psoriasis, paid $6,500 out of his pocket each year to cover 10 per cent of the $65,000 annual drug cost. Spencer adopted the AMS formulary and selected 60/80/100 per cent coinsurance levels on acute/maintenance/speciality medications. Now, Robin pays 40 per cent, or $4 for her $10 eye drops instead of $1, and Bill s specialty medication costs him nothing out-of-pocket. Since there are so many more claims submitted for acute and maintenance medications than specialty medications, and because Spencer s plan has large claim pooling protection, the change to the AMS formulary saves Spencer s organization 11.5 per cent a year in drug claim costs. The case studies within in this document are based on inforce clients and are included for illustrative purposes only. Actual outcomes may vary significantly due to individual circumstance. 6

8 Maintenance Medication Management: Connecting patients with pharmacists Great-West is working with Canada s largest pharmacy chain, Shoppers Drug Mart Inc., on two initiatives to address maintenance medications a drug category that accounts for 60 per cent of drug plan costs. By engaging and providing support to our plan members who require these medications, better health outcomes can be achieved which contributes to effective drug plan cost management. 1. Medication Counseling Program This program s objective is to help plan members who take certain medications for high blood pressure better understand the options that may be available to them. Plan members are invited to call a dedicated toll-free number and speak with a Shoppers Drug Mart pharmacist. The pharmacist will, where clinically appropriate, discuss alternate treatment options using therapeutically equivalent medications. Plan members can benefit from a greater awareness of the therapeutic options available. Those who participate in the program and switch to a therapeutically equivalent medication see a reduction of 83 per cent, on average, in drug ingredient cost 2. This may decrease their out-of-pocket expenses on maintenance medications where coinsurance applies. The plan could see lowered drug costs as a result. The Medication Counseling Program will expand to additional therapeutic classes in $ There is no cost to the plan member or plan sponsor for a pharmacist s consultation as part of the Maintenance Medication Management programs. 7

9 2. Diabetes Support Program Over 9 million Canadians are living with diabetes or prediabetes 3. With the rate of diabetes on the rise, our Diabetes Support Program is designed to help plan members with diabetes learn to better manage their condition through: monitoring of blood sugar levels through the use of an A1C test, medication reviews and lifestyle and medication adherence counseling. Through this free program, plan members and their dependants can book a one-on-one consultation with a Shoppers Drug Mart pharmacist. At the appointment, they may have their blood sugar level tested and receive counseling on proper medication management, diet and nutrition management, all of which may help in lowering their risk of complications. 10 days absent A PERSON WITH DIABETES INCURS MEDICAL COSTS ESTIMATED TO BE TWO TO THREE TIMES HIGHER THAN THOSE OF A PERSON WITHOUT DIABETES 4. FROM A PRODUCTIVITY STANDPOINT, STUDIES HAVE FOUND THAT EMPLOYEES WITH DIABETES ARE ABSENT TWO TO 10 DAYS MORE EACH YEAR 5. Year 1 Highlights from the program s first year Through consultation with a pharmacist, the following results were produced: Results of A1C tests at initial appointments showed 63 per cent of individuals tested weren t at their target blood sugar levels. After a 30-minute intervention with a Shoppers Drug Mart pharmacist at the initial appointment, the number of participating plan members who reached their target blood sugar levels tripled at their three-month follow-up appointments. After pharmacists consulted with a participating plan member s physician, the number of participating plan members who met their target blood sugar levels quadrupled. 2 Ingredient cost is just one component drug pricing. Pharmacy mark ups and dispense fees also contribute to the final price Canadian Diabetes Care Guide: Self-management of Blood Glucose (SMBG) and Type 2 Diabetes by Sheila Walker, RD, CDE, M.Ed, November 20, Diabetes Care, Burden of Diabetes on the Ability to Work: A Systematic Review, Vol. 36, March 2013,

10 Specialty drug developments in the treatment of Hepatitis C Specialty medications can provide life-changing results for patients. These drugs make differences where, in some cases, no treatment was previously available. Coverage for these medications can be made available through a group benefits plan, but it s important to be aware of the impact the associated costs can have. Recently, a number of new drugs have been developed to treat Hepatitis C. According to the Canadian Liver Foundation, an estimated 250,000 Canadians are infected with the virus, with 21 per cent not knowing they have it. The disease is most pervasive among baby boomers, those born between 1945 and 1975, who are up to five times more likely 6 than other adults to be infected. What is Hepatitis C? Hepatitis C is a virus contracted through infected blood that damages the liver. Symptoms include fatigue, lethargy, reduced appetite, sore muscles and joints, nausea, abdominal pain or jaundice. It s the leading cause of cirrhosis and liver cancer and is the number one reason for the need for liver transplantation. Hepatitis C progresses slowly, with many people living 20 to 30 years without symptoms. Hepatitis C stats: UNLIKE HEPATITIS A AND B, THERE IS NO PREVENTATIVE VACCINE. ACCORDING TO THE CANADIAN LIVER FOUNDATION, HEPATITIS C CAUSES 500 DEATHS IN CANADA EVERY YEAR, MORE THAN ANY OTHER SINGLE VIRUS INCLUDING HIV/AIDS AND SEASONAL FLU. ON AVERAGE, THOSE WITH CHRONIC HEPATITIS C MISS 4.15 MORE DAYS OF WORK PER YEAR, AND HAVE LENGTHIER SHORT- AND LONG-TERM DISABILITY ABSENCES THAN EMPLOYEES WITHOUT ,000 Canadians infected 9

11 Treating Hepatitis C Over the last year, Health Canada has approved a number of new drugs for the treatment of Hepatitis C and more are expected. Ranging in cost from $40,000 to over $100,000 for a course of treatment, these new drugs are expensive, but if successful, reduce the need for liver transplant and lower the incidence of liver cancer and even death. 90 % CURE RATE These drugs are truly revolutionary with significantly fewer side effects than previously prescribed drugs, shorter treatment time and a 90 per cent cure rate. 215 % increase in paid claims in 2014 ON OUR BLOCK OF BUSINESS, THERE WAS A 215 PER CENT INCREASE IN PAID CLAIMS FOR HEPATITIS C IN 2014 COMPARED TO THIS CAN BE ATTRIBUTED TO THE INCREASED COST OF TREATMENT AND A HIGHER NUMBER OF PATIENTS SEEKING TREATMENT DUE TO THE MORE TOLERABLE AND EFFECTIVE THERAPIES. Claim cost management The new Hepatitis C medications are already incorporated into our Prior Authorization drug program. Claims for most of the Hepatitis C medications are directed through our designated pharmacy network to further manage cost. Great-West is committed to finding ways to help plan sponsors provide comprehensive coverage while considering drug plan sustainability for the long term. 6 Chronic Hepatitis C: Why Baby Boomers Should Get Tested 7 The Impact of Hepatitis C Virus Infection on Work Absence, Productivity and Healthcare Benefit Costs (Jun Su, Richard A. Brook, Nathan I. Kleinman, Patricia Corey-Lisle) 10

12 Tune in Check out the Great-West Life YouTube page for videos on DrugSolutions topics including Generics and Brand Name Drugs. Educating plan members on the value in switching to generic drugs can help keep your plan costs down. There s also great general material available including Why Care About Your Benefits, demonstrating the value of a group benefits plan. As Canadians, we enjoy access to universal health care, but some services like dental may not be covered. Our commitment Through DrugSolutions, Great-West explores new opportunities to help plan sponsors offer comprehensive group benefits plans and ensure plan members continue to receive the coverage they need when they need it most. We are proud to share the statistics demonstrating the impact of our programs with you and will continue to find innovative ways to help ensure plan members are receiving the best health support possible. M7275-4/15 Great-West Life and the key design are trademarks of The Great-West Life Assurance Company.