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Understanding your health insurance at work


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In this webinar:

● Overview of the structure and operation of Canada’s private drug plan marketplace, including the important distinctions and/or overlaps between private (insurance) and public (government) providers
● Explanation of the role and place of medication coverage within the supplemental health benefits plans of life and health insurance companies which provide pharmaceutical coverage
● Identification of the various providers and influencers which contribute to private formulary (lists of drugs which are covered) decision-making and their roles in the system
● Understanding generally what gets covered, by which plans and under what circumstances and which medications are typically subject to restrictions
● Guidance on how to determine which medications are covered
● Exploration of how patients and caregivers can navigate through the complex private plan system including:
● Who should provide answers regarding coverage and
● What you can do if you run into coverage restrictions / rejections?
● How should patients interact with the private payer community generally?

Contact the presenter:
● @suzannelepage

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Understanding your health insurance at work

  1. 1. 1 “Understanding your health insurance at work” Webinar September 24, 2015 Canadian Cancer Survivor Network (CCSN) Presented by: Suzanne Lepage, Private Health Plan Strategist
  2. 2. 2 Overview 1. Private vs Public Drug Plans 2. Private Market Overview 3. Drug Plan Designs 4. Private Drug Plan Cost Pressures 5. Emerging Trends 6. Patient’s Guide to inquiring about Private Drug Coverage 7. Questions and Discussion
  3. 3. 3 Private vs Public Plans • Employers view drug coverage as part of compensation package, not for health • Private payers don’t have the same transparency as public plans • Confidential “Business to Business” transactions • Concern about competitors gaining market intelligence
  4. 4. 4 Private vs Public Plans • Insurers’ specific drug coverage decisions or criteria rarely communicated publicly • Confidential communication targeted at their customers: Plan Advisors and Plan Sponsors • Plan Members can access their own coverage information via insurer call centre or secure web portal
  5. 5. 5 Plan Members ~ 19M Plan Sponsors ~400-600K Plan Advisors ~3,000 Insurers ~15 Pharmacies ~9,000 PBM ~3 Unions
  6. 6. 6 Prescribed Prescription /Open Provincial Managed Formulary Frozen /Custom Formulary Formulary Co-pay Multi tiered plans Sliding Coinsurance DeductibleFlat co-pay% Coinsurance Limits Quantity Limits Days Supply Trial Script Ther. Class Limits Ther. Class Incl/excl. Pricing and Maximums Disp Fee Caps Lifetime Maximum Annual Maximum Generic Pricing Allowable Price Plan Sponsor Plan Design Decisions
  7. 7. 7 Private Drug Plan Cost Pressures
  8. 8. 2014 Drug Trend Report • Average annual drug spending per claimant increased by 2.7% (up from 1.3% in 2013) • Spending on traditional prescription medications declined by 0.3% • 12.1% increase in spending for specialty medications o 9.2% increase in cost per script o Utilization grew 2.9% o Represents only 2% of claims, but 26.5% of total spending (up from 24.2% in 2013) o Expected to reach 35% in the next four years. • Top 1% of all claimants comprised 28% of total spending o Total spending for the top 1% = bottom 85% 8 Express Scripts Canada 2014 Drug Trend Report
  9. 9. 9 Emerging Trends
  10. 10. 10 Emerging Trends 1. Case management of drug claims 2. Mandatory generic pricing 3. Increase in preferred provider pharmacy networks 4. Therapeutic substitution 5. Specialty drugs targeted 6. Growth of formularies *These trends are not mutually exclusive. They can be layered on with a “multiplying effect”
  11. 11. 11 “My drug is not covered!!!” Strategies are situational Do you know why drug is not covered?
  12. 12. 12 Possible reasons a drug may not be covered by a private plan Reason Potential Strategy 1 New drug still under review DIN not listed on payers system Ask when review will be completed and decision(s) will be made 2 Drug plan mimics the provincial formulary Provincial formulary doesn’t cover the drug Listing on provincial formulary
  13. 13. 13 Possible reasons a drug may not be covered by a private plan Reason Potential Strategy 3 Drug is part of a class that is excluded/limited on drug plan Employer would have to change drug plan 4 Drug plan is managed formulary Formulary manager has reviewed the new drug and decided not to cover Ask formulary manager why they decided not to cover drug. Clinical or cost effectiveness? Develop strategy to appeal decision
  14. 14. 14 Possible reasons a drug may not be covered by a private plan Reason Potential Strategy 5 Drug Plan has specific criteria that must be met for patient to be covered for drug (diagnosis, prior treatment, step therapy, infusion location) Patient does not meet criteria Ask formulary manager why they decided on specific criteria for this drug If criteria does not align with approved indications or guidelines, develop strategy to appeal decision 6 Drug plan requires that the patient try to access alternate coverage first e.g. special government program Apply for alternate coverage Ask if there is an opportunity for interim coverage by the private plan while they wait for the alternate program to review patient application
  15. 15. 15 Possible reasons a drug may not be covered by a private plan Reason Potential Strategy 7 Drug is covered, but patient has reached their individual maximum on their plan Employer would have to change drug plan or allow patient exception Explore other potential coverage (e.g., catastrophic drug coverage in your province)
  16. 16. 16 Patient’s Guide to inquiring about Private Drug Coverage
  17. 17. 17 1. Ensure you have employee (and spouse if applicable) drug plan: • Contract or policy number • Personal certificate or identification number 2. Get a copy of the benefits booklet that outlines the employer benefit plan 3. Get the phone number for the insurance company 4. When calling the insurance company they will ask which drug the inquiry is about: • Drug name • DIN (Drug Identification Number)
  18. 18. 18 5. If you are told the drug is “Not Covered” get more information on why the drug is not covered • “Can you please explain why this drug is not covered by the plan? • I am not familiar with insurance coverage. Could you help me understand why this plan does not cover this drug? I have the benefits booklet right here. Can you explain to me the specific terms that explain why this drug is not covered?” • “If you are unable to help me, can I please speak to someone who can? Can you transfer me to your supervisor?” • If you are referred back to your employer: • “Thank you, but for privacy reasons, I would rather not discuss my (or my family member’s) medical condition and medication needed with my employer. Can you please explain to me why this drug is not covered?
  19. 19. 19 6. Consider asking your employer (plan sponsor) for an exception. • Because the employer chose the plan, they may have the opportunity to ask the insurer to pay for a drug that is not covered by the drug plan - this is called an “exception” or “extra-contractual coverage” • The ability to request or negotiate exceptions depends a lot on the size of the employer and their financial arrangements with the insurance company • Develop the “business case” of why the employer should cover the drug • If necessary get assistance from a physician or support group to make the case for drug coverage • Put the request and all supporting evidence in writing • Arrange a meeting with a manager, Human Resources or Benefits Department, as appropriate
  20. 20. 20 Summary 1. Private vs Public Drug Plans 2. Private Market Overview 3. Drug Plan Designs 4. Private Drug Plan Cost Pressures 5. Emerging Trends 6. Patient’s Guide to inquiring about Private Drug Coverage 7. Questions and Discussion
  21. 21. 21 Questions and Discussion Suzanne Lepage (519)954-8873 (Business) (519)635-5175 (Cell) @suzannelepage
  22. 22. Canadian Cancer Survivor Network Contact Info Canadian Cancer Survivor Network 1750 Courtwood Crescent, Suite 210 Ottawa, ON K2C 2B5 Telephone / Téléphone : 613-898-1871 E-mail / Web site Blog: Twitter: @survivornetca Facebook: Pinterest: