Insurance & Medication Access

Transcription

1 Insurance & Medication Access Ontario Rheumatology Association 12th Annual Meeting JW Marriott The Rosseau Muskoka May 25, 2013 Suzanne Lepage, Private Health Plan Strategist

2 Learning Objectives Understand the business of private insurance Understand emerging trends in private drug plan designs that may impact patient access to medications

3 Disclosures Amgen Canada has sponsored presentations I have done on Biologics and Biosimilars for private payer audiences and presentations done on private insurance for physicians and patient groups.

4 Overview 1. Private Market Overview 2. Drug Plan Designs 3. Private Drug Plan Cost Pressures 4. Emerging Trends

5 Private Market Overview

6 TELUS Health Analytics (formerly Applied Management Consultants)

7 PBM ~3 Insurers ~15 Plan Advisors ~3,000 Plan Sponsors ~ K Unions Pharmacies ~8400 Plan Members ~ 19M

8 Drug Plan Designs

9 Group Insurance Drug Plans Private plan definition of drug: 1. Drug must be approved by Health Canada and bear a DIN Only for approved indications (no off label) Excludes Natural Health Products (NHP) 2. Includes drugs used to treat a medical condition or illness Excludes drugs used for prevention or cosmetic purposes 3. Group insurance drug plans wrap around government coverage Excludes drugs covered by a government program or provided in a hospital

10 Private plans and hospital drugs Based on insurers view of Canada Health Act: Medically necessary hospital services include drugs, biologicals and related preparations when administered in a hospital considered insured services under the Act should be funded by the hospital global budget typically not covered by private plans

11 Plan Sponsor Plan Design Decisions Formulary Frozen /Custom Formulary Managed Formulary Provincial Prescription /Open Prescribed Co-pay % Coinsurance Flat co-pay Deductible Sliding Coinsurance Multi tiered plans Limits Ther. Class Incl/excl. Ther. Class Limits Trial Script Days Supply Quantity Limits Pricing and Maximums Allowable Price Generic Pricing Annual Maximum Lifetime Maximum Disp Fee Caps Programs Step Therapy Prior Authorization Case Mgmt. Pref. Prov. Network Therapeutic Subs. Gov t Integration

12 Private Drug Plan Cost Pressures

13 Private drug plan costs Private drug costs doubled between 2000 and Private drug costs grew 0.5% in More Rx per person and more people claiming Utilization +0.3% 2 Growth in specialty drug use + changes in therapeutic mix Therapeutic mix = change in mix of conditions + drugs used to treat Brand Inflation Avg brand Rx + 2% 2 1-Express Scripts Canada 2009 Drug Trend Report 2-Express Scripts Canada 2011 Drug Trend Report

14 Specialty Drugs 1. Requirement for frequent dosage adjustments and intensive clinical monitoring 2. Need for intensive patient training and compliance assistance 3. Limited or exclusive product availability and distribution 4. Specialized product handling and/or administration requirements 5. Generally, cost more than $500 per month Biologics are specialty drugs Not all specialty drugs are biologics Express Scripts Canada

15 Express Scripts Canada 2011 Drug Trend Report Specialty (biologic) drugs 19% of drug spend < 1% of claims Avg cost per Rx is $1,242 [vs $49 for other drugs] 12% per year increase [vs 1.9 decrease for other drugs] Est. to be 25-30% of spend in 2016

16 Chronic disease Low cost, high volume Crowded therapeutic areas Highly Genericized Biologic/specialty medications High cost, low volume

17 Emerging Trends

18 Emerging Trends 1. Case management of drug claims 2. Mandatory generic substitution 3. Increase in preferred provider pharmacy networks 4. Therapeutic substitution 5. Oncology and biologic drugs targeted 6. Growth of formularies *These trends are not mutually exclusive. They can be layered on with a multiplying effect

19 1. Case management of drug claims Insurer reviews physician's proposed treatment to ensure that it is reasonable May identify alternative treatment options to attending physician Monitor patient s adherence to the treatment plan Could limit payment or decline drug claim when the patient does not cooperate with health case management or adhere to their treatment plan. Treatment plans and outcomes may be

20 1. Case management of drug claims Great West Life Health Case Management implemented in 2012 for 14 biologic drugs for 7 conditions (Ankylosing spondylitis, Chrohn s Diease, Multiple Sclerosis, Psoriasis, Psoriatic Arthritis, Rheumatoid Arthritis, Asthma) Sun Life considering program Manulife - considering program

21 2. Mandatory generic substitution Generic Substitution Plan: If a brand name drug has a lower-cost generic alternative, the generic product will be automatically substituted and dispensed for the "name brand" alternative. If the patient requests the brand name drug instead of the generic the difference in cost would be paid by the patient. If Dr. writes no sub on the Rx, patient will be reimbursed for the brand name drug. Mandatory Substitution Plan: Only lower-cost generic alternative will be

22 2. Mandatory generic substitution In the past a plan sponsor would choose if they wanted a generic plan and which kind of plan they wanted. Some carriers are now making Mandatory Generic Substitution plans a standard Great West Life making all their contracts Mandatory Generic Substitution by 2013 Sun Life - Eff. May 2012 all new contracts will be mandatory generic - existing contracts at next renewal. Medavie Blue Cross - Eff. May 2013 existing insured contracts < 50 employees Equitable Life April 2013 Implementing on all group plans

23 3. Increase in preferred provider pharmacy networks Private plan can require patients to purchase their drugs from a preferred supplier in order for the claim to be reimbursed. Pharmacies usually agree to certain services, competitive dispensing fees and drug prices for private plans that select them as preferred providers. Pharmacy makes up for lost revenue through increased volume. Express Scripts Canada - Home Delivery Pharmacy (Canada Post, CP Rail, Desjardins Insurance) GWL Pharmacy Network Value Plan Costco GWL - HealthForward Inc. (division of Amerisource Bergen (formerly Innomar)) - Requires Plan Members (patients) to

24 4. Therapeutic substitution Private plan may only pay for a different drug than the one originally prescribed by a patient's doctor. Medavie - pilot in Atlantic Canada Express Scripts Canada Active PBM Home Delivery Pharmacy Great West Life Lower cost interchangeable drug Reasonable treatment Therapeutic class pricing Shoppers Drug Mart Medication Counselling Manulife Step Therapy

25 5. Oncology and biologic drugs targeted A drug may be covered or listed on a private formulary, however the insurer may be subject the drugs or patient to restrictive access hurdles Sun Life and TELUS - Enhanced Prior Authorization (Immunology and Oral Cancer) GWL Case Management GWL Enhanced Prior Authorization Sun Life and Manulife Enhanced Government Integration Sun Life - Prior Authorization on all plans eff. March 2013

26 6. Growth of formularies Plan sponsors feel they can no longer afford to cover all drugs Considering managed formularies - where their drug plans only pay for effective and affordable drugs. They are looking for formulary managers to help them Sun Life - Reformulary Group evidence-based formulary Manulife - Managed Formulary (MMF) & Dynamic Therapeutic Formulary (DTF) Most formularies are still primarily two tiered. Preferred drugs on tier 1 reimbursed more, however most other drugs covered on Tier 2 and reimbursed at lower coinsurance.

27 Emerging Trends 1. Case management of drug claims 2. Mandatory generic substitution 3. Increase in preferred provider pharmacy networks 4. Therapeutic substitution 5. Oncology and biologic drugs targeted 6. Growth of formularies *These trends are not mutually exclusive. They can be layered on with a multiplying effect

28 Questions? If you have: Questions Examples Specific cases Want to discuss insurance issues in more detail? 10:45 11:45 am Workshop 6: Insurance access Room: Windermere

29 Thank you Suzanne Lepage (519) (Business) (519) (Cell) 29

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