This presentation discusses innovative pathways to drug access in private drug coverage plans. It notes that many players are involved in private drug plans, including insurers, plan members, plan sponsors, advisors, insurance carriers, pharmacy benefit managers, and pharmacies. It also discusses some of the cost containment measures commonly used by private drug plans, such as generic substitution, tiered formularies, therapeutic substitution, prior authorization, and case management. In closing, it emphasizes getting to know your private drug plan and how plan design can impact access to medications, as well as noting the complexity of coordinating benefits between different plans.

1. Presentation to Expert Patients Forum
Innovative Pathways to Drug Access in Private Drug
Coverage Plans
November 19, 2015
Glenn Monteith
Vice President Innovation and Health Sustainability
November 19, 015
1

2. Players involved in private market – insurers and
others
Plan
Members
19 Million
Plan
Sponsors
500,000+
Advisors &
Consultants
3,000
Insurance
Carriers
24
Pharmacy
Benefit
Managers
3
Community
Pharmacies
8,600
• Many players and decision-makers are involved in private
drug plans

3. Diseases Have Major Impacts on Canadian Economy
Diseases affect productivity at work, both physically and/or mentally
Examples:
3
1 Source: http://www.phac-aspc.gc.ca/media/nr-rp/2011/2011_0919-bg-di-eng.php
2 Source: Cranswick K., Dosman D. Eldercare: Canadian Social Trends. 2008, Vol. 86, pp. 48-56 and Fast, et al. A Profile of Canadian Chronic Care
Providers: A Report Submitted to Human Resources and Development Canada. Univ. of Alberta. Edmonton : s.n., 2002.
$7,000 / employee / year
Presenteeism
$10,000 / employee / year
Abstenteeism
• The Public Health Agency of Canada has estimated that the costs of
these diseases on the economy are over $200 billion every year
• Half is due to patients being unable to work1

4. Chronic Diseases Have a Big Impact on Productivity
and Absenteeism
Top 15 drivers of lost work time Total cost of condition of employees
with a primary condition
4
Source: Kessler’s HPQ—Adjusted to work Force (2007) Source: Collins et al, Assessment of chronic conditions
on work performance, absence and total economic
impact for employers, NEOJM, 2005

5. Cost containment measures
used by private drug plans
5

6. Generic substitution
• Not mandatory – physician may prescribe innovative medicine and
write “no substitution”
• Mandatory – in all cases, a generic drug, if available and considered
“interchangeable” then it will be dispensed, or, plan only pays up to
cost of generic drug and plan member must pay the difference in
price to access the innovative medicine *exceptions process for
some plans
Get to know your plan options and ask questions of your pharmacist/
pharmacy when getting a prescription filled.
6

7. Prior Authorization GWL 100+ Drugs

8. Tiered Formulary

9. Therapeutic Sub / Mac Price

10. Case Management

11. Summary of Scorecard Findings – 2013 Actuals
• PDP drug cost growth in 2013 is the lowest in recent years.
• Drug cost growth of 2.2% was in line with the Forecast CAGR (1.6% to
2.8%) for the 2013-2017 forecast period.
• Generic savings was higher than forecast; as anticipated generic pricing
changes had the greatest impact.
• Impact from new medicine entry was lower due to a mix consisting of
fewer specialty medicines than forecast.
• Though marginal, the aging event had a slightly higher impact than
forecast due to growth in the number of older claimants and increase in
utilization amongst these older claimants.
11

12. Closing thoughts
• Private drug plans are important to providing access to innovative
medicines and vaccines
• Get to know your plan and inform yourself of how plan design
features can impact access
• Coordination of benefits between plans (e.g. public and private or
two private plans) can be complex
Rx&D advocates for timely, quality access to innovative medicines and
vaccines so people get the treatments they need when they need them.
12