Approximately 70% of Canadians use an insurance benefits plan to cover the cost of prescription drugs. (Source: CLHIA Facts and Figures 2019). Most of these are employer-sponsored group benefits plans.
It is important to understand that group insurance plans can vary widely. They don’t all cover the same drugs or cover them in the same way. An employer-sponsored group insurance plan is designed to meet the needs of the employer and what that employer can afford. If the employer is simply focused on providing a basic level of care to its employees, it may only cover a limited number of routine prescriptions. If the employer wants to attract and retain highly trained individuals, or meet the demands of a union, it may offer more coverage of drugs for a range of conditions. If the company you work for is small or independently owned, you may have a smaller insurance drug plan than someone who works for a large corporation or is part of a large union. Some companies offer different types of plans (e.g. gold, silver, bronze level plans) that have varying levels of coverage.
Most insurance drug plans are carefully managed and want to ensure that treatment drugs are being used for the correct indication. For this reason, many insurers will want a “Prior Authorization” form completed for many different cancer drugs. This allows them to check the reason the drug is being used, what is expected from its use, and if there are other drugs that should be tried first. An oncology drug access navigation can help identify if your insurance drug plan needs this type of form completed and have it completed by your oncologist.
If the insurance plan agrees to cover the cost of your drug, how much you pay, for how long, and under what conditions will depend on the design of your plan. The design depends on what features the employer has chosen to suit its needs and budget. An oncology drug access navigator will help you determine the following:
Co-payment – the amount you pay at the pharmacy; this may be a % of the cost or a set $ fee
Deductible – a one-time amount you pay at the beginning of the plan year, before the insurance company will pay anything toward the drug
Dispensing fee – an additional fee you pay directly to the pharmacy for their services; not all insurance plans cover the dispensing fee for their members
Plan Maximum – a limit on the amount the insurance company will pay toward your drugs in a given year or a lifetime; not all insurance plans carry maximums, but it is important to check, as many cancer treatments taken at home are costly and can quickly exhaust an insurance plan maximum amount
Plan Restrictions or substitutions – some insurance plans have specific restrictions that may apply to the drug you need; a plan may not cover certain types of drugs, it may restrict how much you can fill at any one time, or it may require you to take the generic version of a drug if one is available
Preferred Pharmacy requirements – some plans include specific arrangements with a specific pharmacy or network of pharmacies; you may be asked to fill your prescription for the drug at a certain location; an oncology drug access navigator can help you determine your options and whether this is required
Julie is referred to the Oncology Drug Access Navigator (DAN) by her oncologist. She has recently been diagnosed with a Stage III cancer and has been prescribed a take-at-home cancer treatment. This is the only type of treatment for her cancer and is standard of care. The purpose of the referral was to help Julie determine how much coverage she has for the drug on her plan, because the drug costs $5,000 per month and she needs to take it for at least eight months.
Julie has an employer-sponsored group insurance plan but has never had to use it. She has only been with this employer for a year. The DAN places a call to the insurer with Julie present, who gives her permission over the phone for the person at the insurer to speak with the navigator. Together, they determine that the drug Julie has been prescribed is a “Prior Authorization” drug and will require pre-approval before being covered. The DAN has the form that is required and will have the oncologist complete it. They also determine that Julie has 70% coverage for prescription drugs, so will have a copayment per month of approximately $1,500. Julie has an annual maximum on her plan of $50,000 per year, which should suffice for the time she needs to take this drug, although it may impact the amount of coverage she will have left for other drugs.
Following the call, the DAN speaks to Julie about her options for copayment assistance. The DAN also encourages Julie to speak to her employer to see if there is a higher tier of coverage that she may be able to apply for, to increase her plan maximum amount. They set a follow up appointment for later in Julie’s therapy to see if any additional help may be required.
*fictional case; any similarities to actual patient cases are coincidental