Have Your Say
A role in drug plan management
DEBBIE ELLEN
The launch of Viagra in the U.S., and most recently in Canada, has triggered not only a barrage of media attention and consumer demand, but it also caused some anxiety among drug plan sponsors worried about whether they should cover the drug. This issue offers a perfect opening for pharmacists to explain why they–as drug experts–are uniquely qualified to help employers choose how and which drugs should be included in a drug plan.
Many Canadian drug plans have been experiencing double-digit annual cost increases due to an aging workforce, government cost-shifting, new expensive drugs and increased awareness of drug therapy. To address this, employers have typically depended on cost control measures they can manage themselves (i.e., better administration, cost-shifting to employees and capping mark-ups and fees). The realization that a single drug could increase plan costs in one year by two to eight per cent has forced many to look for other solutions.
Most employers want to control costs while ensuring employees and their families have access to drugs they really need. At the same time they want to minimize the financial impact of improper drug use or abuse. In effect, they want the right drug for the right person, at the right time, in the right dose, at the right price. Ultimately, employers will need a combination of rigorous screening for drug appropriateness and cost-effectiveness by pharmacists at the time of dispensing, together with clinically-based formulary design.
The following list suggests a process by which pharmacists could work with employers, insurers and other groups to help manage drug costs:
- set up a drug classification matrix system for new, expensive or highly publicized drugs, keeping in mind that a single drug may fall into conflicting categories for different patients; include categories such as medically necessary, lifestyle-enhancing, for disease treatment and for prevention
- quantify the financial impact for each classification based on drug claims history; focus on the areas generating high claims dollars or posing significant future risk
- identify the employer’s drug plan objectives. Is the plan simply meant to pay for the drugs or to provide what is necessary for the health of employees and their families?
- develop an effective decision-making process for deciding which existing drugs and which drugs awaiting DIN approval will be covered; evaluate possible coverage options for each (such as full coverage, prior authorization criteria, etc.), and select the most appropriate process
- make presentations to achieve employee and union buy-in
- write text to update plan documents and union contracts; provide education for users of flexible plans or spending accounts
- ensure the formulary and coverage restrictions are complied with at the retail pharmacy level
When all is said and done, remember to track savings. Measure the financial impact of formulary and drug coverage recommendations. It is the only way to clearly demonstrate a business case that will enable pharmacists to sell the value of this type of consulting service today and for a long time to come.
DEBBIE ELLEN, B.Sc.Phm., is the Manager of Client Relations at Pharmasave Drugs National, in Langley, BC