Navigating Private Insurance in Canada

REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 1

“Navigating Private Insurancein Canada”

WebinarNovember 30, 2017

Canadian Cancer Survivor Network (CCSN)

Presented by: Suzanne Lepage, Private Health Plan Strategist


Overview1. Unique Characteristics of Private Payers

2. Private Payer Stakeholders

3. Private Payer Coverage

4. Private Drug Plan Cost Pressures

5. Private Payer Trends

6. Declines and Appeals

7. Patient’s Guide to inquiring about Private Drug Coverage

8. OHIP+ and Private Plans

9. Questions and Discussion

REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC.

Canadian Drug ExpendituresPublic Private Split

3

63.6%

36.4%

Private

Public

CIHI 2017

62.0%

38.0%

Insurer

Out of Pocket


Private Payer Share Much Larger in CanadaRetail spending on pharmaceuticals by type of financing, 2015 or nearest year


Canadian Health Insurance Facts

CLHIA - Canadian Life and Health Insurance Facts - 2017

REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC.6

Unique Characteristics of Private Payers


Private payers are different

• Employers view drug coverage as part of compensation package, not for health.

• Managed by Human Resources – not health care providers

• Stakeholders are suppliers and competitors

• Insurers target “customer” = plan sponsors (employers)

• Confidential “Business to Business” transactions

• Insurer’s priority relationships with their customers -plan advisors and plan sponsors

• Lack of transparency

• No obligation that plans, coverage decisions shared publicly


Private payers are different

• Concern about competitors gaining market intelligence

• 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


1. Premiums based on the makeup of their group and claims experience from previous years

2. Pool charges for extra risk protection for claim costs that go over a threshold e.g. $10,000 per year

Employers pay for health benefits


Private Payer Stakeholders

10


Plan Members

~ 19M

Plan

Sponsors

~400-600K

Plan

Advisors

~3,000

Insurers

~15

Pharmacies

~9,000

PBM

~3

Unions


Private Payer Coverage

12


All private plans are different• Some private plans may cover a drug and some may not

• Coverage can vary

• within one insurer

• even within one employer

• Individual employers choose coverage for their employees

• They decide what they want to cover and how much coverage (except QC)

• Their premiums are based on the plan design and actual claims

• Each insurer offers a wide variety of plans to meet different needs

• Some plans may cover your drug and others may not

• Different prices for different plans

14


All private plans are different

• Access is more than – “is the drug covered?”

• There can be other features that will impact an individual patient access via their private drug plan

For example:

1. Prior authorization

2. Plan maximums

3. Step Therapy

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PrescribedPrescription

/OpenProvincial

ManagedFormulary

Frozen/Custom

FormularyFormulary

Co-payMulti tiered

plansSliding

CoinsuranceDeductibleFlat co-pay% Coinsurance

LimitsQuantity

LimitsDays

SupplyTrial

Script

Ther. Class

Limits

Ther. ClassIncl/excl.

Pricing andMaximums

Disp Fee

CapsLifetime

Maximum

AnnualMaximum

Generic

Pricing

AllowablePrice

Plan Sponsor Plan Design Decisions


Private Drug Plan Cost Pressures


Private Drug Plan Claim Costs

• Average eligible amount per cardholder $445

• Up 5.8% from 2015

• Specialty drugs (>$10,000)

25.9% of total claims costs

0.96% of number of claims

• Average annual amount per claimant

$18,549 for specialty drugs

$509 for non-specialty

Source: TELUS Health 2016 Drug Trend Report


Private Drug Plan Premiums

• 65% of employers experienced cost increases in their benefit plan1

• 66% report total benefit costs have increased over the past 3 years3

• 80% are concerned that growing costs will exceed the rate of inflation over the next 3-5 years3

1. TELUS Health. http://www.bppgcreative.ca/pdfs/b/bc-medication-management-drug-benefit-plan-cost.pdf.

2. Sanofi Canada Healthcare Survey 2015. http://www.sanofi.ca/l/ca/en/layout.jsp?scat=C3588838-0978-4F25-9A92-6F37FA912C05.

3. Sanofi Canada Healthcare Survey 2016. http://www.sanofi.ca/l/ca/en/layout.jsp?cnt=65B67ABD-BEF6-487B-8FC1-5D06FF8568ED.

http://www.bppgcreative.ca/pdfs/b/bc-medication-management-drug-benefit-plan-cost.pdf

http://www.sanofi.ca/l/ca/en/layout.jsp?scat=C3588838-0978-4F25-9A92-6F37FA912C05

http://www.sanofi.ca/l/ca/en/layout.jsp?cnt=65B67ABD-BEF6-487B-8FC1-5D06FF8568ED


Private Payer Trends


Private Payer Trends1. Increased scrutiny of pipeline and new drug submissions

2. Case management of drug claims

3. Preferred provider pharmacy networks (PPN)

4. Increased focus on Prior Authorization

5. Integration – provincial drug plans and Patient Support Programs

6. MAC – Maximum Allowable Cost

7. Step Therapy

8. Growth of managed formularies

9. Delayed Listings

10. Plan Maximums (annual or lifetime)

11. Product Listing Agreements


Declines and Appeals


“My drug is not covered!!!”

Strategies are situational

Do you know why drug is not covered?


Possible reasons a drug may not be covered by a private plan

Reason Potential Strategy

1New 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




3Drug 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




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 firste.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




7Drug 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)


Types of Appeals

Medical

• Situational - based on specific reason for patient decline

• Need to know why coverage was declined• Patient doesn’t meet criteria?

• Payer doesn’t cover drug?

• Physician appeals to insurer

• Makes case for medical necessity

• Explains why alternate (covered) treatments aren’t sufficient for this specific patient

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Types of AppealsEmployer

• Situational - based on specific reason for patient decline

• Need to know why coverage was declined• Specific plan chosen by employer does not cover this drug?

• Provincial mimic or managed formulary?

• Employer is ultimate payer who chooses coverage and has the ability to change it or make an exception

• Employee appeals to their employer

• Requires disclosure of condition

• Develop “business case” of why employer should cover drug

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Patient’s Guide to inquiring about

Private Drug Coverage


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)


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?


OHIP+ and Private Plans

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• 2017 Ontario budget

• New drug program effective January 1, 2018

• Offers free medication to Ontarians < 25 yrs who are covered by OHIP

• Coverage will be provided regardless of family income or private insurance benefits and enrollment in OHIP+ will be automatic.

• Ontario is investing $465 million to provide youth with access to 4,400 Ontario Drug Benefit (ODB)



• Employers increasingly concerned about growing drug plan costs

• OHIP+ seen as a way to relieve cost pressures by transferring expenses and risk to ODB

• In order to maximize potential savings

• Will make changes to their coverage for this age group

• Will have downstream impacts on patient access to medication



Maximize provincial coverage and transfer the claims risk to the ODB

1. Eliminate all drug coverage for plan members < 25 yrs

2. Eliminate coverage for ODB drugs for plan members < 25 yrs

3. Require plan members < 25yrs to apply for EAP coverage before approving private coverage

How private coverage could change


Private Plans - Transition strategy – EAP Drugs

January 1 – June 30, 2018

Insurance carriers will continue to cover the following drugs without

requiring an EAP rejection:

1. Antibiotics and anti-infectives (including antiviral and antifungal

agents)

2. Blood thinners (low molecular weight heparins)

3. Drugs with low EAP approval rates


• All other EAP drugs will be handled on a insurer by insurer basis

• May require EAP rejection in order to approve private coverage

a. as of January 1, 2018

b. or allow a grace period

• Insurance carriers still developing their communication plans

• Many will develop custom communication to plan member/patient

who are taking an EAP drug which will provide specific direction

Private Plans - Transition strategy – EAP Drugs


Summary1. Unique Characteristics of Private Payers

2. Private Payer Stakeholders

3. Private Payer Coverage

4. Private Drug Plan Cost Pressures

5. Private Payer Trends

6. Declines and Appeals

7. Patient’s Guide to inquiring about Private Drug Coverage

8. OHIP+ and Private Plans

9. Questions and Discussion


Questions and DiscussionSuzanne Lepage

(519)954-8873 (Business) (519)635-5175 (Cell)

[email protected]

www.suzannelepage.caca.linkedin.com/in/suzannelepage/

@suzannelepage

mailto:[email protected]

http://www.suzannelepage.ca/


Canadian Cancer Survivor Network Contact Info

Canadian Cancer Survivor Network

1750 Courtwood Crescent, Suite 210Ottawa, ON K2C 2B5Telephone / Téléphone : 613-898-1871E-mail [email protected] or [email protected]

Web site www.survivornet.ca

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Navigating Private Insurance in Canada

Healthcare

Transcript of Navigating Private Insurance in Canada