TRENDS & DECISION
DRIVERS IN PRIVATE
PLANS
OPMA Seminar
Martin Chung April 3, 2014
mchung@equitable.ca
 Who is providing benefits?
 What is covered?
 How much is covered?
 Who is driving plan design decisions…and why?
 I...
WHO IS PROVIDING BENEFITS (I)
EMPLOYER SEGMENTATION BY SIZE
Vast majority of workplaces are small-mid in
size
[NOTE: Emplo...
WHO IS PROVIDING BENEFITS (II)
EMPLOYER SEGMENTATION BY #EE
Majority of Employees work for small-mid
Employers
Are you inf...
 “OPEN” PLAN: Exception based plan design where
all Rx requiring +/- OTC are eligible with the
exception of specific drug...
Image Source: Google
 Open Plans still prevalent
 Eligibility no longer automatic on Open Plans
 Slow progression to Closed Plans
 Larger e...
 Mandatory generic pricing
 Adjustment to dispensing fee
 Annual or per Rx deductible
 Co-insurance
 Multi-tier co-in...
 1980 RARELY A NEED TO ASK
 1990 WHAT VERSUS HOW MUCH IS COVERED
 2000 WHAT VERSUS HOW MUCH IS COVERED
 >2015 WHAT VER...
 24 Carriers provide group benefit products
 PBM?
 Advisors (over 100,000 can sell group benefits)
 Employers (to less...
IS MUTUALLY BENEFICIAL
COLLABORATION POSSIBLE?
Image Source: Google
 What does above brand mean?
 Rx&D
 Evidence
 B2B
...
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Trends & decision drivers in private plans. By Martin Chung

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Presentation by Martin Chung at OPMA's breakfast session on April 3, 2014.

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Trends & decision drivers in private plans. By Martin Chung

  1. 1. TRENDS & DECISION DRIVERS IN PRIVATE PLANS OPMA Seminar Martin Chung April 3, 2014 mchung@equitable.ca
  2. 2.  Who is providing benefits?  What is covered?  How much is covered?  Who is driving plan design decisions…and why?  Is mutually beneficial collaboration possible? EXPLORE QUESTIONS THAT MATTER
  3. 3. WHO IS PROVIDING BENEFITS (I) EMPLOYER SEGMENTATION BY SIZE Vast majority of workplaces are small-mid in size [NOTE: Employers (especially small) do not always provide benefits]
  4. 4. WHO IS PROVIDING BENEFITS (II) EMPLOYER SEGMENTATION BY #EE Majority of Employees work for small-mid Employers Are you influencing all employer segments?
  5. 5.  “OPEN” PLAN: Exception based plan design where all Rx requiring +/- OTC are eligible with the exception of specific drugs or categories.  CLOSED (aka. MANAGED) PLAN: Inclusion based plan design where only specific DINS are eligible. FOUNDATIONAL DEFINITIONS
  6. 6. Image Source: Google
  7. 7.  Open Plans still prevalent  Eligibility no longer automatic on Open Plans  Slow progression to Closed Plans  Larger employers more willing to limit what is covered TRENDS ASSOCIATED WITH WHAT IS COVERED
  8. 8.  Mandatory generic pricing  Adjustment to dispensing fee  Annual or per Rx deductible  Co-insurance  Multi-tier co-insurance +/- “Americanization”  Lifetime drug maximum  Annual drug maximum  Etc. etc. etc…. TRENDS ASSOCIATED WITH HOW MUCH IS COVERED
  9. 9.  1980 RARELY A NEED TO ASK  1990 WHAT VERSUS HOW MUCH IS COVERED  2000 WHAT VERSUS HOW MUCH IS COVERED  >2015 WHAT VERSUS HOW MUCH IS COVERED THE WHAT VS. HOW MUCH TRANSITION
  10. 10.  24 Carriers provide group benefit products  PBM?  Advisors (over 100,000 can sell group benefits)  Employers (to less or greater degree depending on size)  Ancillary providers WHO DRIVES PLAN DESIGN DECISIONS? Do you have balance, reach, and acute awareness of influence levers? Current approach will not work
  11. 11. IS MUTUALLY BENEFICIAL COLLABORATION POSSIBLE? Image Source: Google  What does above brand mean?  Rx&D  Evidence  B2B  Transparency

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