While much of the talk has been about conditions such as hepatitis C, a number of other diseases are likely to start taking a bigger bite out of benefits plans in the coming years. Some of the drugs associated with them can be pricey, but plan sponsors still have time to prepare.
Drug claims from some cancer patients have already reached $150,000 a year, says Priscilla Po, senior manager of clinical services and drug plan management at Express Scripts Canada in Mississauga, Ont. And as oncology medications become more effective, people live longer, she notes. “Instead of just two months, they’re living two years, five years . . . 10 years,” she adds, noting patients also need maintenance drugs during that time.
The biggest concern around cancer medication is “the shift from public to private,” says John Herbert, Express Scripts’ director of strategy, product development and clinical services. “Where the drug was maybe administered in a hospital setting, now we’re seeing more take-home, self-administered cancer medications.” Provincial health plans don’t always cover those drugs.
And those at-home drugs are getting more expensive. JAMA Oncology recently reported oral cancer medications approved in 2000 cost $1,869 each month, while those approved in 2014 cost $11,325 per month. And with 1,813 cancer drugs in development, Po and Herbert expect costs to keep rising.
But whether employers will see those costs depends on where they operate. “Essentially, all cancer treatment is available to Albertans and British Columbians,” says Bill Bright, pharmacy practice leader for Western Canada at Willis Towers Watson in Calgary. Still, he’s seeing plan sponsors paying for more and more oncology treatments, either because the province hasn’t approved some commonly prescribed drugs or employees make claims on their insurance, “rather than filling out the paperwork” required by their provincial cancer agency.
2. High cholesterol
Statins “are the really low-cost therapies [for high cholesterol], yet they’re very effective,” says Po. But many patients aren’t prescribed a high enough dose, don’t take the drugs correctly or keep eating triple bacon cheeseburgers. When tests still show high cholesterol, their doctors may think the statins aren’t working and prescribe PCSK9 inhibitors instead. Those drugs, introduced in mid-2015, work for part of the population, according to Po. The concern, however, is overuse, she adds.
Some plan sponsors “find it easy to just not cover the medication at all, just to prevent the risk of over utilization by the bigger population,” says Herbert, who notes the problem with that approach as well. “I would almost call it not very Canadian,” he adds.
Instead, Express Scripts suggests extensive reviews of patient eligibility, including their adherence to high-potency statins and assessing the medication’s effectiveness after 12 weeks.
Hepatitis C isn’t the only liver condition around. Patients with non-alcoholic steatohepatitis (NASH) drink little to no alcohol but have fatty buildup in and inflammation of their livers, says Po. NASH affects two to five per cent of the population, especially those who are obese or who have diabetes or high cholesterol. NASH currently has no treatment.
Po is following three drugs currently undergoing clinical trials and expects approval for one of them in 2018. She anticipates the drug may also get approval for a rare autoimmune disease, which could signal high prices. “This is why we are very concerned,” she says.
Sara Tatelman is an associate editor at Benefits Canada.
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