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In case you missed it… Drug Plan Management

It’s nearly impossible to watch the news without a story related to the opioid crisis in Canada.  Most of the crisis is attributable to one drug – fentanyl.  This was one of two drug related topics presented by Margaret Wurzer (BSc. Pharm., MSc.) Senior Manager, Benefits and Product Development at Alberta Blue Cross at our April 19th  lunch session.

The province of British Columbia has declared a public health emergency.  Here in Alberta there were 349 fentanyl related deaths last year and 51 in the first six weeks of 2017 of which nearly half (25) were right here in Calgary.  Fentanyl related deaths are just the tip of the iceberg as there were nearly 20,000 fentanyl related emergency and urgent care visits in Alberta related to misuse of opioids and other substances between January 2014 and September 2016, which is about 20 per day. This poses a significant drain on healthcare resources.

The use of opioid narcotics is not just limited to street users.  For an employer with about 1,000 employees, approximately 13% or 130 will be taking some kind of narcotics for pain relief at any point in time and three of those employees are likely to be abusing them.

So what can employers do to help prevent narcotic abuse on their benefit programs and ensure employees that are abusing narcotics get the treatment they need?

  1. Implement opioid coverage controls that include prior authorization or limits. The controls can be clinically based (i.e., morphine equivalents), or subject to a specific dollar amount. Wurzer suggest that clinically based measures are more accurate if the Pharmacy Benefits Manager (PBM) can administer it on that basis. New draft guidelines for non-cancer pain treatment with morphine should be prescribed at less than 90 mill equivalent per day, which is in line with U.S. Federal Drug Administration (FDA) guidelines.  Setting dollar limits can be a little more difficult to establish as monthly dosages for narcotics can range from 2 to 8 pills per day at costs ranging from about $50 to $200.
  2. Provide coverage for drugs to treat opioid dependence such as methadone (Methadose®) and buprenorphine – naloxone (Suboxone®)

Maximum allowable cost (MAC) pricing or reference based pricing was the focus of the second part of Ms. Wurzer’s presentation.  She says the BC and Alberta government plans have been using MAC pricing for over 20 years, so this is not a new concept.  Under MAC pricing a low cost drug that is deemed to be effective for treating a particular medical condition is selected as a reference point for the reimbursement of all other drugs in a particular class. If the plan member is prescribed a drug, which has a higher cost than the MAC drug, they can either get their doctor (or pharmacist in Alberta) to change their prescription to the MAC drug; or pay the difference out of pocket.  Either way the plan saves money. Similar to generic substitution, if the plan member is unable to take the MAC drug due to an adverse reaction, they can apply for an exception.

Wurzer says this is another tool plan sponsors can use to manage drug costs for long-term plan sustainability, while giving employees a choice to take any drug they want, notwithstanding some financial consequences.

This session provided some great insight into two lesser known areas where plan sponsors can focus their drug plan management efforts.

  • Kenneth MacDonald

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