To manage growing drug plan costs, private payers are implementing several plan designs to manage specialty drug use:
- Special or prior authorization: A patient or their physician must submit additional information for the insurance carrier to review to ensure the patient meets specific criteria before coverage is confirmed. The review could include clinical information, prior treatments and/or diagnosis.
- Case management: Case management is like special or prior authorization but requires much more information to be provided to the insurance company’s case manager who will review the treatment plan and consult with the physician. Case managers may recommend an alternate treatment or monitor the patient to ensure that they obtain the best possible outcomes.
- Preferred pharmacies: Some private plans require patients to use a pharmacy or chain exclusively, and others cover more of the cost for patients who use these pharmacies. Some insurers have partnered with specialty pharmacies for exclusive distribution of biologic treatments to patients.
- Managed formularies: Their drug plans pay for a predetermined selection of effective and affordable drugs. Their insurance carrier or pharmacy benefit manager will manage the formulary on behalf of the employer.
How to navigate drug coverage
Talk to your pharmacist to learn what coverage options are currently available to you. Your medication may qualify for public coverage, private coverage, or both. Some coverage may be available automatically while others may require certain documentation or other steps to be completed first.
You can also explore the Canadian Skin Patient Alliance’s drug coverage finder, Is My Prescription Covered?here to see what coverage may be available to you.
Some private insurance plans may require patients to meet a pre-set deductible before they can start having the cost of their drug covered. You may need to call your insurance provider to learn the specific details for your individual plan.
If you have been denied coverage or the co-pay is unaffordable, here are some options we recommend:
- Write to your Human Resources Manager and request an employer exception. When the insurance carrier says a drug is not covered, it is usually because the specific insurance plan chosen by the employer does not cover the drug. The insurance carrier is following the terms of the insurance contract chosen by the employer. Because the employer chose the plan, they may be able to ask the insurer to pay for a drug that is not covered by the drug plan. This is called an “exception” or “extra-contractual coverage”. Any exceptions must be agreed upon by both the insurer and the plan sponsor (whoever makes the plan available to you, i.e., your employer, union, etc.) and this may affect the price of the whole insurance plan. To accommodate a special request, the employer and insurer will look at the details of the drug plan to see if additional premiums are needed to accommodate a claim for a drug that was not included in the initial plan and premium calculation. This avenue of exceptions depends a lot on the size of the employer and the financial arrangements with the insurance company. Large employers may have more flexibility to negotiate an exception with their insurance carriers, although they may not have the budget or wish to set a precedent. In the end, each request is made on a case-by-case basis and reviewed against the terms of the specific contract in place.
- Cost is an important consideration when starting any drug therapy. Talk to your doctor about what treatment options are available and ask if there are any cost considerations you should know about. Your pharmacist may also be able to provide you with more insight to the cost of various treatments and coverage options to help you look at all factors before deciding on your treatment approach.
- Consider exploring other options such as patient support programs.
