With providers of dental and paramedical services closed, many aspects of the benefits plans are seeing reduced use. But drug plan spending is continuing unabated — and experts say new concerns are coming up during the crisis.
Plan sponsors that have implemented 90-day supplies as a cost-control measure may have to see if their plan can be adapted during the crisis, says Suzanne Lepage, a private health-plan strategist. Multiple provincial pharmacy colleges are now following a Canadian Pharmacists Association recommendation to limit prescriptions to 30-day supplies to prevent drug shortages.
“It’s worth . . . making sure that [plan members are] not penalized because of a new mandate that’s out of their control,” says Lepage.
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While some public payers have offered relief from the additional co-pay costs during the crisis, Joe Farago, executive director of private payers and investment at Innovative Medicines Canada, notes plan sponsors may see increased dispensing fees due to the change.
As well, plan sponsors with preferred pharmacy networks may need to make changes to their plan to accommodate plan members now working from home, says Lepage. “Maybe we get our drugs near our office or get it delivered to our office, so . . . the way we receive or who we get our drugs from may change.”
For plan members who are already on specialty drugs or biologics and will require a renewal at some point during the crisis, process will also have to change. Normally, patients are required to undergo lab tests or will receive a renewal from their physician for an insurer to approve. “Clearly, with labs being closed, it’s difficult to [meet] the testing requirements,” says Farago. “It’s also difficult to see your doctor, because they’re not seeing [patients] in person.”
The insurance industry was quick to address the problem, he adds. “We saw, over the course of a few weeks, a slow response by insurers to change their process whereby they allowed for a simpler renewal process without the usual requirements. They almost all have some kind of process now in place.”
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In a statement to Benefits Canada, the Canadian Life and Health Insurance Association said its members recognize the need to be flexible during the crisis. “Patients may not be able to access their physician or obtain lab tests to provide information normally required to support a drug prior authorization renewal.
“To ensure treatment continues, health insurers will be allowing extensions of prior authorization renewals without this information during the crisis. As approaches may vary, patients with private insurance requiring a prior authorization renewal should check their insurer’s website or, if there are still questions, contact their insurer for more information.”
While the IMC welcomes the change, Farago notes it’s a temporary solution that may need to be re-addressed if the pandemic lasts longer than insurers’ extensions. Most are accommodating simpler renewals for a period of three to four months.
Plan members who were in the process of getting prior authorization for a specialty or biologic drug for the first time are in a more challenging position, he adds, and may need to wait until the crisis ends. Lack of access to physicians and lab testing makes the situation more challenging. “It seems like, for new patients, the old process is in place. Practically speaking, very few patients are starting on new medications now.”
Indeed, new patients are being handled by insurers on a case-by-case basis, “given the complexity,” the CLHIA told Benefits Canada.
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Farago says it’s still unclear what will happen to Canadians under private drug plans who are laid off during the crisis. “That’s a big concern. What happens to those individuals who are on drugs and all of a sudden lose their private drug insurance?”
A temporary transition to a provincial plan would be easier in some provinces than others, he notes. Quebec and British Columbia have public drug programs covering the majority of their residents, for example, whereas Ontario’s drug plan doesn’t cover those aged between 25 to 64.
It’s a concern the Ontario Rheumatology Association echoed in a statement to Benefits Canada.
“Many of our patients have been marginalized, living with chronic, painful illnesses impacting quality of life and employability,” it said. “Many have suffered tenuous employment and rely on private insurance to cover the prohibitive costs of life-saving, independence-sustaining therapy. Economic forces have been escalating for some time, even before the current global issues with the COVID-19 pandemic. And many of our patients have been abandoned as a result of lost employment, and are now at the very real risk of catastrophic disease progression with the abrupt discontinuation of therapy.”
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