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Pour Employeurs
Choisir le bon régime

Les choix que vous faites aujourd’hui peuvent avoir une influence sur l’avenir.

Choisir le bon régime d’assurance-maladie et d’assurance médicaments pour votre organisation favorise une main-d’œuvre en santé, augmente la satisfaction des employés et contribue à votre résultat net.

Il y a de nombreux facteurs à examiner lors de la sélection d’un régime, notamment vos objectifs pour le régime, le nombre d’employés, les besoins de votre main-d’œuvre, et votre budget. La plupart des employeurs achètent des prestations dans le but de permettre aux participants de profiter des traitements les plus appropriés et les plus opportuns.

Pour gérer les budgets, les employeurs peuvent envisager d’adopter des mesures pour réduire les coûts, mais la plupart de ces mesures limitent l’accès des employés aux médicaments nécessaires. Par exemple, on peut influencer le choix de la thérapie, la retarder ou la refuser, ou influencer la méthode d’accès (gestion de cas, RFP, etc.). D’autres mesures imposent un plus grand partage des coûts pour les employés par des franchises plus élevées, des primes ou des montants de copaiement. Limiter le montant des prestations payables aux employés, comme les plafonds annuels ou à vie pour les médicaments, peut faire économiser de l’argent à court terme, mais il ne s’agit pas d’une solution à long terme.

Il est important de connaître les implications de toutes ces mesures pour vos employés et de quelle manière elles ont une incidence sur l’accès au bon traitement au bon moment; qui pourraient avoir un impact négatif sur la santé de vos employés et qui comportent également un coût caché : une baisse de la productivité des employés et un impact sur votre résultat net.

Les employeurs doivent évaluer les coûts et les bénéfices lorsqu’ils offrent des régimes d’avantages sociaux complets qui attirent et retiennent les meilleurs employés. Au moment où la complexité des régimes augmente, il est important de travailler avec une ressource de confiance pour vous aider à comprendre les répercussions à court et à long terme sur les employés et votre entreprise.

Dans l’environnement actuel de fournir des prestations de santé de haute qualité tout en gérant les coûts de votre régime, un « plan d’hygiène » devient une priorité pour de nombreux employeurs. Un plan d’hygiène fait référence à la santé globale et à la conception de votre régime. Il peut y avoir des options simples pour améliorer les coûts de votre régime global tout en ayant un impact minimal sur l’accès aux médicaments des participants. Travailler de concert avec votre fournisseur pour limiter les marges bénéficiaires, les frais d’exécution et la fréquence des renouvellements pour les médicaments de maladies chroniques ne sont que quelques exemples.

Types de conception de régime et leurs répercussions sur l’accès des employés aux thérapie

(chaque crochet représente un impact négatif sur l’accès du participant au régime)

Légende

Traitement différé
Augmente le fardeau financier
Fardeau administratif/étapes supplémentaires
Traitement sous-optimal
Refuser l’accès

Caractéristiques de régimes d’assurance-médicaments Traitement différé Augmente le Fardeau Financier Fardeau administratif/étapes supplémentaires Traitement sous-optimal Refuser l’accès
Preferred Pharmacy Network (PPN)
CARACTÉRISTIQUES
Preferred Pharmacy Network (PPN)

A network of pharmacies that agree to provide guaranteed levels of service, competitive dispensing fees and drug prices for the plans that participate in the network.

IMPACTS POSSIBLES
  • May make it difficult for some employees to fill their prescription.
  • PPN pharmacy may not be convenient for the employee and their family.
  • Pharmacist may not be aware of all the medications that employees are receiving – an important role for ensuring proper medication.
Case

Margaret and her family live in a rural area, which requires a 45 minute round trip to the nearest PPN pharmacy, instead of using her local pharmacy which is in the same town that she visits to bank, grocery shop etc.
Deductibles/Co-payments
CARACTÉRISTIQUES
Deductibles/Co-payments

The portion of the claim cost that must be paid by the plan member.

IMPACTS POSSIBLES
  • The employee’s level of coinsurance (the amount the employee has to be paid out of pocket) for their drug may be unaffordable.
  • For a $30,000 per year drug, a 20% copayment is $6,000
  • This may result in the employee skipping or foregoing their treatment due to cost.
  • Poor adherence can result in poor health outcomes, which can impact an employee’s productivity, absenteeism or disability.
Case

Wilma’s drug plan has a 20% co-insurance and she is on chronic medications for treating diabetes and hypertension. Recently, she has had a number of extra expenses. In order to save some money, she has decided to skip taking her medication the odd day. Her physician is still concerned that her therapy is not working as well as it should, and thus prescribes a more intensive and expensive therapy.
Prior Authorization/ Special Authorization
CARACTÉRISTIQUES
Prior Authorization/ Special Authorization

Drug claim will only be approved if the patient meets pre-defined medical criteria set out by the payer.

 

IMPACTS POSSIBLES
  • Increases administrative burden and may result in employees receiving sub-optimal therapies, or long delays before starting therapy.
Case

Carol’s rheumatoid arthritis (RA) is not responding to first line therapies and her rheumatologist recommends she tries a biologic treatment. When she gets to the pharmacy with her prescription she finds out that prior authorization is required.

She contacts her insurance carrier and gets the necessary form. This requires her to return to the rheumatologist to get the form completed. It may take up to 6 weeks to get another appointment.

Once she has the form completed by the doctor she submits to the insurance carrier and must wait 4 weeks for a response.

During this waiting period, her RA continues to remain poorly managed and she has to take additional days off work.
Generic or Mandatory Generic Pricing
CARACTÉRISTIQUES
Generic or Mandatory Generic Pricing

If a brand name drug has a lower-cost generic alternative; the plan will reimburse up to the price of the generic product.

 Often the pharmacist will automatically substitute and dispense the generic, however, the patient can request the brand name drug and the pay the difference in price.

 In a “traditional” generic plan, if the doctor indicates “no substitution” on the prescription, the plan will reimburse the price of the brand name drug.

 In a “mandatory” generic plan, the plan will only reimburse the brand if the doctor provides medical evidence that the patient cannot tolerate the generic drug.

IMPACTS POSSIBLES
  • Some generic drugs are not comparable to the brand medication and there may be variation even between different generic versions.
Case

Geoff’s 8-year-old son Tyler is taking medication to control his ADHD. While taking the brand medication Tyler was a good student at school and was socially competent. Since he switched to the generic medication which had a different way of releasing the medication, Tyler has not been able to function as well as he had been previously. Geoff has had to take considerable time off from work to deal with Tyler’s behavioural and learning issues, as well as to take Tyler to additional appointments with the specialist.
Step Therapy
CARACTÉRISTIQUES
Step Therapy

Drug plan requires the claimant to try and fail on drug A (typically lower cost) before being eligible for drug B.

IMPACTS POSSIBLES
  • Step therapy can ensure that patients try older, lower cost therapies first before using, newer higher cost therapies.
  • This can save the plan money, however sometimes step therapy can delay access to the most appropriate and effective medications.
Case

Harpreet has been recently diagnosed with atrial fibrillation and the physician wishes to prescribe a blood thinner. Harpreet’s drug plan requires him to initiate therapy with an old, inexpensive therapy for several months, however, this therapy is not as effective as newer medications. During this period of time, Harpreet needs to take time off work to go for testing and has a significantly increased risk of stroke compared with the newer medications.
Maximum allowable costs (MAC), Lowest Cost Alternative (LCA) or Reference Based Pricing
CARACTÉRISTIQUES
Maximum allowable costs (MAC), Lowest Cost Alternative (LCA) or Reference Based Pricing

Drug plan sets reimbursement limits for medications that fall within specific therapy classes and caps the maximum amount reimbursed under the drug plan for certain drugs at the price of the corresponding “reference drug” in each class.

IMPACTS POSSIBLES
  • Some of the newer, innovative therapies may offer improvements or innovations that will increase treatment effectiveness or patient adherence.
  • Drugs have different side-effect profiles or drug interactions
  • If patients are not getting the drug they need or experience side effects, they may choose not to take their medication.
  • The employee may only be reimbursed for a lower cost drug than the one they are on.
  • If they cannot afford to pay the difference, this may require them to stop their current treatment and try an alternate medication that may not work for them.
Case

John’s medication is only reimbursed up to the lowest cost drug in his therapy class. He cannot afford to pay the cost differential and takes the lower cost drug. Unfortunately, it has different side effects and sometimes results in him leaving work early or taking a day off.
Therapeutic Substitution or switching
CARACTÉRISTIQUES
Therapeutic Substitution or switching

When a patient switches a drug from what is prescribed. Could be because of medical need, affordability or plan design.

IMPACTS POSSIBLES
  • Could impact an employee’s ability to receive the most appropriate medication.

Mahmood has been diagnosed with depression and it is affecting his ability to do his work. There are a number of medications that could be effective in treating his condition, however, his physician is limited in the choices that can be prescribed due to the restrictive nature of Mahmood’s benefit plan. The medication he is prescribed has an increased likelihood of causing side effects that will be detrimental to his performance at work.
Tiered Plans
CARACTÉRISTIQUES
Tiered Plans

When drugs are grouped into different categories, each with a different reimbursement level.

IMPACTS POSSIBLES
  • Could impact an employee’s ability to receive the most appropriate medication.
Case

Mahmood has been diagnosed with depression and it is affecting his ability to do his work. There are a number of medications that could be effective in treating his condition, however, his physician is limited in the choices that can be prescribed due to the restrictive nature of Mahmood’s benefit plan. The medication he is prescribed has an increased likelihood of causing side effects that will be detrimental to his performance at work.
Managed Formularies
CARACTÉRISTIQUES
Managed Formularies

When a third party is “managing” the formulary and making clinical and cost-effectiveness decisions about which drugs will be covered.

IMPACTS POSSIBLES
  • Could impact an employee’s ability to receive the most appropriate medication.

Mahmood has been diagnosed with depression and it is affecting his ability to do his work. There are a number of medications that could be effective in treating his condition, however, his physician is limited in the choices that can be prescribed due to the restrictive nature of Mahmood’s benefit plan. The medication he is prescribed has an increased likelihood of causing side effects that will be detrimental to his performance at work.
Maximum Limits/caps Annual/Lifetime
CARACTÉRISTIQUES
Maximum Limits/caps Annual/Lifetime

When the plan sponsor limits the amount they will pay for benefits. This could be a separate cap for all health benefits, or for drugs only.

IMPACTS POSSIBLES
  • Low limits on drug expenditures can have catastrophic results for employees who take a large number of different drugs, or who require breakthrough treatments that have a high price tag.
Case

Cindy has just been diagnosed with a rare, deadly form of cancer for which new cancer therapies have been shown to be particularly effective in treating – so effective, in fact, that some people with this type of cancer appear to have been cured. These new therapies also have fewer side effects and many employees are able to work while undergoing their treatment. The drug manufacturer’s patient support program is willing to cover the co-pay for this new medication, however, Cindy’s lifetime cap is too low for her to start therapy. Due to the cost, Cindy is forced to receive a medication that has significant side effects, and her likelihood of returning back to work is greatly reduced.
Provincial Formulary Mimic
CARACTÉRISTIQUES
Provincial Formulary Mimic

When a private plan mimics the provincial drug plan for the list of drugs they will reimburse.

IMPACTS POSSIBLES
  • Could impact an employee’s ability to receive the most appropriate medication.
Case

Mahmood has been diagnosed with depression and it is affecting his ability to do his work. There are a number of medications that could be effective in treating his condition, however, his physician is limited in the choices that can be prescribed due to the restrictive nature of Mahmood’s benefit plan. The medication he is prescribed has an increased likelihood of causing side effects that will be detrimental to his performance at work.
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