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

1. TRENDS & DECISION
DRIVERS IN PRIVATE
PLANS
OPMA Seminar
Martin Chung April 3, 2014
mchung@equitable.ca

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. 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. WHO IS PROVIDING BENEFITS (II)
EMPLOYER SEGMENTATION BY #EE
Majority of Employees work for small-mid
Employers
Are you influencing all employer segments?

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. Image Source: Google

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.  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.  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.  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. IS MUTUALLY BENEFICIAL
COLLABORATION POSSIBLE?
Image Source: Google
 What does above brand mean?
 Rx&D
 Evidence
 B2B
 Transparency