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
CaseMargaret 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. |
x | ||||
Deductibles/Co-payments CARACTÉRISTIQUES
Deductibles/Co-payments
The portion of the claim cost that must be paid by the plan member. IMPACTS POSSIBLES
CaseWilma’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. |
x | x | x | ||
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
CaseCarol’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. |
x | x | x | ||
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
CaseGeoff’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. |
x | x | x | ||
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
CaseHarpreet 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. |
x | x | x | x | x |
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
CaseJohn’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. |
x | x | x | ||
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
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. |
x | x | |||
Tiered Plans CARACTÉRISTIQUES
Tiered Plans
When drugs are grouped into different categories, each with a different reimbursement level. IMPACTS POSSIBLES
CaseMahmood 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. |
x | x | x | ||
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
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. |
x | x | x | x | x |
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
CaseCindy 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. |
x | x | x | ||
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
CaseMahmood 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. |
x | x | x | x | x |