Biosimilars, pharmacogenetics helping to shape the future of pharmacy benefits management

Plan sponsors with growing concerns about benefits plan sustainability should focus on a few strategic pharmacy benefits plan issues, said Mark Rolnick, executive vice-president of pharmacy innovation and patient experience at Green Shield Canada, during a session at Benefits Canada’s Face to Face Drug Plan Management Forum on Dec. 9, 2020.

He recommended that plans consider the impact of biosimilars, gene therapy, pharmacogenetics and implementation of pharmacy services to support plan member health care. “Many plans haven’t properly adopted biosimilars on their plans, which results in dollars being wasted,” said Rolnick, recommending increased utilization of biosimilars as a key strategy to effectively manage drug plans. Although Green Shield has seen results from their aggressive approach to biosimilar use, he said the organization realizes it still has a long way to go and that it can’t do it alone.

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There are opportunities to proactively engage the health-care community, such as pharmacists and doctors to increase the use of biosimilars in Canada. “It’s important to get biosimilars right and create room for high-cost treatments, such as gene therapies, which are the next big wave.”

Although gene therapies offer ground-breaking results, their accompanying six-digit price tags make them a challenge to manage, Rolnick said. While gene therapies aren’t on most plan sponsors’ minds, Canadian health-care stakeholders need to come together to co-ordinate on how best to provide coverage to these needed therapies. “The insurance industry needs to come together to figure out what solutions can be put in place, either alone or in partnership with the government.”

Rolnick said pharmacists have also had a growing and cost-effective role in primary care as their scope of practice has expanded (such as vaccine delivery), providing an opportunity for private plans to work with the pharmacy community to manage health benefits plans. He cited Green Shield’s pharmacy cognitive programs, which reimburse pharmacists who support plan members with smoking cessation programs or disease management for conditions like asthma or diabetes.

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Pharmacogenetics can also help private plans can improve patient care and reduce costs, he said. While benefits plans have primarily used pharmacogenetic testing as a disability plan management tool to find the best anti-depressant treatments, plans can determine the best treatment at the outset by using these tests prior to prescription.

Reflecting on the forum’s earlier presentations on prior authorization, Rolnick said although it’s an important function to manage drug plans, it focuses primarily on high-cost drugs, which represent approximately one per cent of all claims. “I wonder if this is the best use of energy, or whether we should focus efforts on programs that impact a broader plan-member base.”

Read more stories from the 2020 Face to Face Drug Plan Management Forum.