Panel: Should drug coverage for certain conditions still be optional?

In many workplace drug plans, medications that treat certain conditions remain in the optional life category, but is this structure still valid today?

The optional life category has traditionally been referred to as “lifestyle,” said Rob Taylor, executive vice-president at TRG Group Benefits and Pensions Inc., a division of Hub International Ltd., during a panel at Benefits Canada‘s 2019 Vancouver Benefits Summit at the Fairmont Waterfront on May 24.

“So what I’d say is, as an industry, we get tethered into doing something and it’s very tough to break out of it and break those bonds.”

Read: Opportunities around drug coverage for traditional ‘lifestyle’ issues

Five issues for which there’s still a problem are erectile dysfunction, fertility, obesity, smoking cessation and vaccines, he said. “With some carriers, . . . they say some are lifestyle-oriented and some are optional. They place them in a newly defined category, what we would call an optional drug category.

“The point being that the drugs have been separated out from a standard formulary. A plan sponsor and an advisor — an intermediary — have to sit down and have a conversation about those classes or those specific drug entities. And the conversations that you have to have around those five types of drugs . . . I don’t know at the end of the day if most advisors are equipped to have those appropriate, educational conversations.”

Indeed, the fact that these drugs are called optional or lifestyle-related doesn’t really reflect reality, said Dr. Ali Zentner, medical director at Revolution Medical Clinic, also speaking on the panel. “What do you all think about when you hear the word ‘lifestyle’? You think it’s a person’s choice; they chose that. Well, people don’t choose to have erectile dysfunction. People don’t choose infertility.”

However well-intentioned, people bring their own biases into the room when having discussions about benefits plan coverage, she noted. “If you have fertility issues, five men sitting around the table talking about fertility, it’s a different conversation than five men sitting around the table talking about erectile dysfunction.”

Read: City of Toronto staff’s high claims on ED drugs raise fraud questions

Obesity is a condition where people’s biases come into play, said Dr. Zentner. “We know that obesity is a disease; it’s not a lifestyle choice. It’s a complex, multi-faceted illness with genetic predispositions that affect how we carry our weight, how we respond to treatment.”

Treating something like obesity as a choice is both dangerous and unscientific, she added. “There’s no place for that kind of morality in medicine.”

Also speaking on the panel, Michael Wortzman, scientific advisor at GlaxoSmithKline, said vaccines is another area requiring a shift in perceptions.

“When vaccines became the norm, they were focused on infectious diseases, communicable diseases and they were very much a public health concern because you wanted to control infections that could potentially kill a large percentage of your population,” he said. “At the time, especially in the 1900s, we had a large group of our population that were kids. If you think of it now, child vaccinations programs are very ingrained in our society. They’re very normal . . . . It’s less thought of in the adult space.”

Read: Disease, health-care cost reductions among opportunities for plan sponsors around vaccines

But that’s changing, noted Wortzman, because demographics are changing. “Right now, we’re at an all-time high of the percentage of the population in the workforce and that’s continuing to rise.”

When deciding what treatments are optional in terms of benefits coverage, plan sponsors need to have an updated understanding of what vaccines can be used for, he said.

“There’s now a shift in vaccine science to address chronic conditions. They’re called therapeutic vaccines, so they’re not there to prevent the disease, but actually treat it.”

Conditions like autoimmune diseases, allergies, chronic obstructive pulmonary disease and even cancer are all now potentially part of the universe of what vaccines can ameliorate.

Read more articles from the 2019 Vancouver Benefits Summit.