With the cost of drug claims continuing to rise in 2021, benefits plan sponsors can enable certain drug programs to curb costs, keeping their plans sustainable and offering the benefits that members highly value, said Lavina Viegas, director of pharmacy operations at Telus Health, during a session at Benefits Canada’s 2022 Face to Face Drug Plan Management Forum in Toronto in December.
However, before making major changes, she suggested plan sponsors ensure basic drug plan features are enabled for some quick wins to help with cost sustainability. One of the simplest ways, she said, is to ensure plans are mandatory generic, where the plan reimburses the cost of the lowest generic equivalent even if the physician writes no substitution on the prescription. If the patient wants the brand name, they can pay the difference between the generic and brand cost.
About 55 per cent of Telus Health’s plans are already mandatory generic, while 33 per cent have optional generic, where the cost of the brand name drug is reimbursed if the physician writes no substitution on the prescription. “I think what’s surprising is that 12 per cent do not have any generic plan setup, so they’re probably more at risk from a plan exposure perspective,” said Viegas, encouraging plan sponsors to assess their generic penetration to see if there are opportunities for improvement.
Prior authorization for a drug based on medical criteria ensures patients are using medication appropriately, she added, noting it isn’t designed to limit access to the medication; rather, it aims to ensure they’re using it in alignment with clinical criteria. Viegas suggested provincial drug program coordination is added to ensure claims are also submitted to provincial drug plans wherever appropriate to share the claims costs.
Step therapy can also be useful for diseases that impact a larger number of Canadians, such as diabetes, blood pressure or cholesterol. For these conditions, prior authorization isn’t optimal due to the high volume of claims, she said, noting automated step therapy looks at a patient’s claims history to ensure they’re using a step one drug, which is generally more cost-effective. These steps can be based on therapeutic guidelines for specific conditions, added Viegas.
In addition, several provinces have introduced a biosimilar switching policy, which can have a downstream impact on private drug plans. When a province announced a switching policy, Telus Health noted a change in physician behaviour, she said. Prior to the implementation of the provincial program in British Columbia, for example, 88 per cent of Telus Health patients were on a biologic; two years later, the same percentage of patients were on biosimilar products. “We’re seeing a very similar trend in other provinces.”
Viegas said it’s important for private plans to join the biosimilar switching policy trend and leverage provincial integration wherever possible. There are several different approaches, she added, citing the examples of mimicking provincial policies and delisting the biologic or cutting back biologic claims to the cost of the biosimilar.
If a biosimilar claim replaced every biologic claim, it would work out to savings of 3.8 per cent, according to analysis by Telus Health. “That’s significant when we’re talking about an average seven per cent year-over-year growth,” said Viegas. “At that point, every percentage point matters.
“Bending the cost curve is certainly a challenge, but there are solutions that can be explored,” she added.
Read more coverage of the 2022 Face to Face Drug Plan Management Forum.