In 2020, Canada Life Assurance Co. saw a decrease in the number of benefits plan members making a drug claim, though the costs of those claims were higher, according to Barb Martinez, the insurer’s national practice leader in drug solutions, speaking during a session at Benefits Canada‘s Face to Face in Drug Plan Management Forum in December.
Diabetes was the top therapy class for the past two years, whereas biologic response modifiers were No. 1 for many years and dropped to second place in 2019. “We might even continue to see those drop because there are biosimilar drugs entering those categories,” she said, noting benefits plan sponsors need to be proactive to manage their plan costs.
“While the philosophy and objectives may differ among plan sponsors, there are core elements of drug plan design that should be the basis for most plans,” said Julia Furino, pharmacy consultant in the drug strategy team at Canada Life, during the session.
The workplace impact can be addressed by health technology assessments for private plans, noted Furino, in contrast to a “public payer HTA, [which] focuses on the needs of the public payer and cannot be directly applied to the private payer.”
She suggested plan sponsors consider the clinical and economic impacts of a new therapy using the private payer perspective, “what the treatment means for the plan member, as well as the plan sponsors and drug plan sustainability.” This includes an analysis of the impact on a working age population, which may include the potential to prevent absenteeism, presenteeism and disability or bring disabled plan members back to work sooner.
Product listing agreements is another strategy to mitigate risk, said Furino, which may include specific coverage criteria, lowering the cost of the drug or providing additional patient support.
Prior authorization supports plan members’ health outcomes while maintaining plan sustainability, she said, and requires doctors to complete and submit a form with patient medical information for the insurer to assess. According to Furino, “an effective program requires clinical expertise to develop evidence-based criteria and support reviews of complex cases.”
The growing volume of prior authorization requests is expected to rise given the number of specialty medications in the pipeline. Electronic prior authorization can digitize the forms and submission process. “[This] not only improves the customer experience, but also decreases the administrative burden,” said Furino, noting electronic prior authorization is common in the U.S. and growing in Canada. “We believe this is the way of the future.”
Some specialty medication costs can be equal to or exceed the cost of a disability claim, she added, “so it makes sense to integrate case management program principles that are traditionally used in disability management to support plan members with certain chronic conditions that require high-cost medications.”
Drug case managers work directly with patients to manage their complex treatment plans. “Not only do these programs benefit the plan member, but they also benefit the plan sponsor as they’re often applied to high cost, high utilization, specialty drugs.”
The arrival of lower-cost biosimilars for many specialty medications requires an effective biosimilar strategy to generate savings, said Furino. “Evidence indicates there is no clinically significant difference in safety and efficacy between originator biologics and biosimilars and, therefore, implementing a biosimilar strategy is yet another way to manage the dual bottom line.”
She noted there are two main types of biologics patients: treatment naive patients who have never been established on an originator biologic treatment and experienced patients who are already receiving treatment with an originator biologic.
Treatment naive patient can only be reimbursed for a lower cost biosimilar or can choose the originator or the biosimilar and be reimbursed only up to the cost of the biosimilar. For treatment experienced patients, insurers can align with provincial switching programs or reimbursement can be limited to the cost of the biosimilar.
As new drug innovations such as gene therapy and drugs for rare diseases enter the market, “we need to focus on a benefits plan design to ensure future sustainability,” said Martinez.
Read more coverage of the 2021 Face to Face in Drug Plan Management Forum.