Navigating Private Insurance in Canada

REPRODUCTION REQUIRES PERMISSION OF SUZANNE LEPAGE CONSULTING INC. 1
“Navigating Private Insurance
in Canada”
Webinar
November 30, 2017
Canadian Cancer Survivor Network (CCSN)
Presented by: Suzanne Lepage, Private Health Plan Strategist

Overview
1. 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 Expenditures
Public 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 Canada
Retail spending on pharmaceuticals by type of financing, 2015 or nearest year

Canadian Health Insurance Facts
CLHIA - Canadian Life and Health Insurance Facts - 2017

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
15

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

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.

Private Payer Trends

Private Payer Trends
1. 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
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

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

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

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)

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
28

Types of Appeals
Employer
• 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
29

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
33

• 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

Summary
1. 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 Discussion
Suzanne Lepage
(519)954-8873 (Business)
(519)635-5175 (Cell)
suzanne@suzannelepage.ca
www.suzannelepage.ca
ca.linkedin.com/in/suzannelepage/
@suzannelepage

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 jmanthorne@survivornet.ca or mforrest@survivornet.ca
Web site www.survivornet.ca
Instagram: @survivornet_ca
Twitter: @survivornetca
Facebook: www.facebook.com/CanadianSurvivorNet
Pinterest: http://pinterest.com/survivornetwork/

Navigating Private Insurance in Canada

Recommandé

Recommandé

Contenu connexe

Tendances

Tendances (8)

Similaire à Navigating Private Insurance in Canada

Similaire à Navigating Private Insurance in Canada (20)

Plus de Canadian Cancer Survivor Network

Plus de Canadian Cancer Survivor Network (20)

Dernier

Dernier (20)

Navigating Private Insurance in Canada