A look at medical cannabis coverage’s growing pains

After the Arthritis Society’s extensive advocacy for medical cannabis research, it seemed only natural for the organization to cover the drug under its employee benefits plan.

In 2017, as it prepared to introduce the coverage, it brought together an expert panel, including doctors with extensive experience prescribing medical cannabis and expert pharmacists and advisors from its own scientific and research community, as well as its benefits consultant.

“We wanted to make sure . . . the level of coverage and the way in which we were managing our coverage was going to be as effective as possible,” says Cheryl McClellan, the society’s chief operations officer.

Read: Sanofi survey finds plan sponsors split on issue of medical cannabis

The Arthritis Society covers medical cannabis for chronic pain relating to arthritis and a number of other conditions; chemotherapy-induced nausea and vomiting; and spasticity related to multiple sclerosis, all of which have a “sufficient body of research” indicating the drug can make them more manageable. Employees receive a $5,000 annual maximum with an 80 per cent reimbursement.

They can also claim up to $150 for a virtual or in-person consultation with a physician or other cannabis expert about the best dosage and strain. And they can be reimbursed for up to $300 for a vaporizer if it’s determined that’s the best way for them to take the drug. For consultation services, the Arthritis Society provides a list of prescribing experts across the country.

“We did want to ensure that, from a consultation perspective, people who were accessing medical cannabis were getting the best possible advice in terms of form and dosage,” says McClellan. “There is a cost associated [with that] and, by offsetting that cost for people, it just helps ensure their quality of care is that much better.”

Since the organization introduced medical cannabis coverage in February 2018, two employees have received approval to use it, she adds. It also developed a guide for other employers considering coverage, which includes information on designing a program that sufficiently addresses employees’ needs, health and safety concerns and how to navigate authorization.

Read: Sounding Board: How to deal with medical marijuana in the workplace

While the Arthritis Society has heard from many employers, and McClellan estimates it’s handed out around 1,000 toolkits, the organization is still at the vanguard of medical cannabis coverage. A year after Canada legalized recreational cannabis, few employers are currently covering the drug or offering any supporting services, say consultants and insurers, though more and more plan sponsors and members are seeking information. For employers looking at medical cannabis coverage, what associated options should they consider making available to their employees?

The coverage landscape

When the Arthritis Society introduced coverage, it enlisted Cubic Health Inc.’s licensed pharmacists to adjudicate the claims and authorize its insurer to pay them. “The insurance company, because there isn’t a [drug identification] number for medical cannabis, wouldn’t adjudicate the claims,” says McClellan.

While medical cannabis has been legal since July 2001, it took the legalization of recreational cannabis in October 2018 for employers and insurers to start talking about it in earnest in the context of employee benefits, says Paula Allen, vice-president of research, analytics and innovation at Morneau Shepell Ltd.

“The biggest trend is that employers are even starting to think about covering it, because even when it became legal, very few actually did anything to have it covered under their health plans and there really weren’t a lot of good systems,” she says, noting the landscape is now beginning to change.

In the past two years, major insurers, including Great-West Life Assurance Co., Manulife Financial Corp. and Sun Life, have started covering medical cannabis or expanded their existing programs.

Read: Sun Life adding medical marijuana coverage to group benefits plans

Sun Life, which began offering optional coverage in March 2018 as part of its extended healthcare plan, allows plan sponsors to choose an annual member maximum of between $1,500 and $6,000. Initially, it covered five conditions — cancer with severe refractory pain or chemotherapy-induced nausea, MS with spasticity or neuropathic pain, rheumatoid arthritis with pain that has failed to respond to standard treatments, HIV-AIDS with neuropathic pain and palliative care. In April 2019, it added refractory spasticity in spinal cord injuries and refractory paediatric onset epilepsy.

Similarly, Manulife has optional medical cannabis coverage for plan members who are experiencing neuropathic pain, cancer treatment-related nausea and certain forms of MS with associated spasticity. It also has annual maximum coverage recommendations for plan sponsors.

And Great-West Life, which launched its program on Jan. 1, 2019, provides optional coverage for MS, cancer, HIV/AIDS and symptoms related to palliative care, and has three different annual maximums. All three insurers require patients to receive prior authorization.

Insurers have also started providing more information to plan sponsors on how they can reimburse medical cannabis expenses through their health-care spending accounts, in cases where they aren’t interested in offering it as a specific benefit, says Allen.

Even though these options are now available, employers are still moving cautiously. Allen says she’s seen a few plan sponsors starting to cover medical cannabis and more are asking questions and looking into it. “But it’s not significant at this point. It’s just the beginning of a trend. It will take hold over a period of time.”

Read: Employer obligations around medical pot, benefits plans

Cristina dos Santos, director of extended health care, product development and group benefits at Sun Life, agrees. “We were expecting plan sponsors to start slow and go low and that’s exactly what’s happened. It’s been . . . about a year and a half since we’ve launched and we’ve had a nice slow progression, month over month, of plan sponsors adding this to their benefits plans.”

Related services

The Arthritis Society’s medical cannabis coverage in numbers

Up to $5,000 a year for cannabis

80% of employees’ costs are covered

Up to $150 for virtual or in-person consulting services

Up to $300 for a vaporizer

2 employees have used it

Additional services are a crucial piece of the medical cannabis coverage conversation, says Kim MacFarlane, assistant vice-president of group benefits product at Manulife. Prescribing medical cannabis is still a new medical field, and the strain and dose is completely individualized to the biology of the person using it, as well as the condition for which it’s being prescribed. Without support, plan members would have to navigate unfamiliar terrain on their own.

In July 2018, the insurer added to its medical cannabis offering by partnering with Shoppers Drug Mart Inc. on a case management system. Plan members authorized to receive the drug go through a consultation with one of the pharmacy’s specialized experts on the appropriate prescription and receive followups to determine whether the medicine is generating the expected outcomes.

The partnership is integrated into Manulife’s coverage, so employers don’t have to pay extra to receive it. The insurer also issued the drug a “pseudo DIN” so it can track what strains plan members receive and for which conditions.

Read: Manulife, Shoppers Drug Mart launch medical marijuana partnership

“In discussions with our employers, we discovered they were curious but concerned,” says MacFarlane. “On the heels of an opioid crisis and all other forms of abuse and overuse in some areas of benefits plans, we really wanted to offer employers a way to introduce medical cannabis that would manage some of the risks.”

Ryan Weiss, vice-president of product and experience at Great-West Life, says the insurer had similar conversations with its employer clients about their concern for plan members. The company also partnered with Shoppers on a case management program, which is a mandatory part of its medical cannabis offering. After plan members get a prescription from their doctor, they contact a call centre to speak with a pharmacist about which strain and dose is right for them. The insurer also includes direct electronic submissions so plan members don’t have to pay out-of-pocket.

“One of the things we heard loud and clear from employers was that they didn’t want to leave their members high and dry to navigate this world on their own,” he says. “If you don’t have those types of patient-level supports in there, you’re leaving it up to them to be experts. We wanted to put the rigor around it to make sure people were supported, they were getting safe and appropriate dosing and there was a followup process they could call to get information. It’s really holding people’s hands through this. It’s an exciting new treatment option, but it’s an early one.”

Read: Medical questions, regulations create confusion for medical pot coverage

Beyond the variation in strains and dosages, people can turn to numerous licensed producers, says dos Santos. “It can be very confusing for patients. I think having some patient support and care would be very interesting for people who would like to have that service available.”

Annual max

The Arthritis Society covers up to $5,000.

Sun Life offers maximums between $1,500 and $6,000.

Great-West Life and Manulife suggest a variety of maximums to employers.

While Sun Life doesn’t currently offer any additional case management or consultation services, she adds, the insurer is focused on evolving the covered conditions and symptoms. “Our focus has really been on providing coverage to Canadian employers and their members with certain severe and serious medical conditions. . . . We are looking at future roadmap opportunities in terms of potential opportunities in virtual health-care and other areas.”

Unlike the Arthritis Society’s benefits plan, the three major insurers don’t reimburse for vaporizers or other equipment. Weiss says Great-West Life considers it too challenging to validate whether those tools are medically necessary, or if the patient is using them appropriately.

Educational tools

In terms of plan member education, insurers are starting to step up, says Allen, but employers can also be proactive in providing information to employees. “This is a good opportunity for organizations to build an understanding of cannabis as part of their wellness programs. Having that education [around] medical and recreational cannabis, the difference between the two as well as what the process is . . . can be part of an overall health and well-being education.”

Allen suggests plan sponsors highlight the conditions for which there’s strong evidence of success, to prevent employees from trying to claim for indications that aren’t covered, as well as discussing the difference between various strains and making it clear that medical cannabis doesn’t have the ingredients to make patients high. She has also started to see employers looking for lists of health-care providers that are knowledgeable about prescribing cannabis for different indications. “It is an education in and of itself, so having that roster of qualified providers is helpful.”

Read: A roundup of benefits, HR and legal considerations around legalized marijuana

Helen Stevenson, founder and chief executive officer of the Reformulary Group, says employers she’s spoken with want to provide credible resources for employees even if they aren’t yet ready to cover medical cannabis. “There hasn’t been the emergence of a lot of [independent services]: for instance, case management.”

Currently, patients who aren’t receiving coverage through their benefits plan can call a licensed producer and speak with someone to receive an informal recommendation, she says. They can also ask their doctor for a referral to Canadian Cannabis Clinics, which will advise them on correct strain and dose.

The usual suspects

Medical cannabis coverage is currently offered for the following conditions:

  • Neuropathic and chronic pain, related to conditions such as arthritis;
  • Cancer treatment-related nausea and refractory pain;
  • Multiple sclerosis-related spasticity;
  • Palliative care;
  • Refractory spasticity in spinal cord injuries; and
  • Refractory paediatric onset epilepsy.

“Some might argue the Cannabis Clinic model is essentially case management, but they’re all conflicted because they directly earn a fee from a licensed producer for every patient that comes in and gets an authorization,” says Stevenson. “From that perspective, I think there’s still not a lot of credible, trusted options.”

In response to both these issues, the Reformulary Group created a database compiling the available evidence on which conditions and symptoms have been effectively treated with medical cannabis, the products used and their outcomes. “We put that into our version of a formulary, essentially, and make it available to Canadians directly. The big value to them is they’re getting product recommendations.”

Read: Reformulary Group launches medical cannabis formulary

The platform is currently subscription-based, but Stevenson says the company is considering making it available for free. “Essentially, it’s a tool for employers that don’t want to cover [medical cannabis]. They can direct employees to the platform. And for employers that do want to cover it, they could buy subscriptions and make those available to employees.”

The future of cannabis coverage

Mike Sullivan, CEO of Cubic Health, says the majority of his company’s employer clients are either choosing not to cover medical cannabis or are only starting the conversation. Among the few that do cover it, either as a stand-alone benefit or by expanding the options under their health-care spending accounts, the Arthritis Society is the only one that also reimburses plan members for additional services.

“There are lots of really interesting services, but I think a lot of those fees now would be paid for out-of-pocket by individuals or submitted to the health-care spending account . . . . But they’re not actively part of the coverage program.”

Read: A look at four benefits plan models for covering medical marijuana

However, notes Sullivan, it’s only been a year since the legalization of recreational cannabis and coverage of the drug for medical purposes is still in its infancy.

“Down the road, that might become a mandatory component — like you’ve got to go to have consultations with experts and looking at overseeing your regimen, and starting you on a low dose and working you up. I could see the world getting there, but it’s still really early days.”

Kelsey Rolfe as an associate editor at Benefits Canada.