With new drugs and emerging health trends putting pressure on benefits plans, companies are trying to get a handle on the impact on their bottom lines. Here’s a look at three conditions and some of the medications that are likely to affect plan sponsors’ budgets:
Last year, hepatitis C spending “basically tripled” as new antiviral drugs, Harvoni and Sovaldi, hit the market, says Priscilla Po, senior manager of clinical services and drug plan management at Express Scripts Canada in Mississauga, Ont.
Both drugs boast a cure rate of more than 90 per cent, but an eight-week course of one of them, Harvoni, costs $47,000. Nevertheless, Po points out even that may be more cost-effective than two or three slightly cheaper medications taken together. The pressures will only continue with Health Canada having recently approved another drug, Epclusa, to treat hepatitis C.
To control the costs, plans must “go above and beyond just having a physician check a box and [expensive drugs are] going to be approved,” says John Herbert, Express Scripts’ director of strategy, product development and clinical services. The preauthorization process should include reviewing genotypes, fibrosis and cirrhosis statuses and viral loads for “robust utilization management,” he says.
The work for benefits plans doesn’t end there. Bill Bright, pharmacy practice leader for Western Canada at Willis Towers Watson in Calgary, says patient support and case management are also important. The support could include mobile apps to remind patients to finish the course of treatment or calls with a nurse to help manage side effects.
Despite the focus on hepatitis C, non-specialty drugs are a major factor as well, says Mike Sullivan, president of Cubic Health Inc. in Toronto. Four of Cubic Health’s 17 most-prescribed medications in 2015 were to treat diabetes and they’re not all as cheap as first-line drug Metformin, which costs pennies a day.
Also, new research is pointing to the role of various hormones in treating diabetes, says Sullivan. “It’s not just focused on treating insulin. So a lot of these new therapies are in completely brand-new classes that we’ve never had before and they treat things in a very different way.”
Health Canada has approved five new chemicals in newer drug classes, two of which are sodium-glucose cotransporter 2 inhibitors costing $1,000 per patient per year. That compares to $70 for Metformin, Express Scripts’ recently released 2015 drug trends report found.
And while $1,000 is lower than the cost of some specialty medications, Sullivan notes people take these drugs for life. Plus, the number of diabetics is skyrocketing. From 1998-99 to 2008-09, the Public Health Agency of Canada found the prevalence of Canadians diagnosed with diabetes increased by 70 per cent.
In 2014, cystic fibrosis drug Kalydeco was making headlines for its efficacy and its $306,000 price tag. All provinces and territories have since included Kalydeco — at least in some circumstances — in their drug programs, according to Cystic Fibrosis Canada. Last year, private plan spending on cystic fibrosis medications increased 6.6 per cent and overall use increased by 6.4 per cent, Express Scripts’ 2015 drug trends report found. In January, Health Canada approved the drug Orkambi, which “would be available and suitable for almost half of the cystic fibrosis patient population,” says Po. “So it’s very good news from a clinical point of view because more patients can benefit from the new innovation,” she says, noting the $285,000 price tag.
Sara Tatelman is an associate editor at Benefits Canada: sara.tatelman@ rci.rogers.com. An upcoming issue will look at other diseases that could affect benefits plans in the future.
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Correction: Article corrected Aug. 9, 2016, to reflect that all provinces and territories have included Kalydeco in their drug programs. No province or territory has done so for Orkambi.