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Do your patients understand prescription coverage?

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Pavithra Ravi

Prescription coverage sounds far easier than it really is. Medication reimbursement can be a complex path with formularies, coordination of benefits, payment submit exceptions, and various formulary functions. The best way to overcome this challenge is to understand why, who and how it is implemented.

In Canada healthcare is considered a common good and not a commodity to be purchased. For this to be true, medication reimbursement requires suitability. Prescription medication, for the most part, falls under the jurisdiction of the provinces and territories, except for the few exception groups which have federal coverage (such as Status individuals, veterans, etc.). The cost medication regulated by provincial bodies encompasses both in-hospital and out-of-hospital medication. However, once a patient has left primary hospital care the rules around how and what is covered change.

When a patient is no longer in hospital care, prescription medication costs become out of pocket, with some provincial assistance. As of 2017, the national percentage of individuals who do not qualify for some sort of coverage, whether that be private or publicly funded, was 1.8%. This means the majority of Canadians have some form of prescription coverage. However, access to drugs may be restrictive due to coverage limits, preferred provider networks, deductibles, and so on. There are numerous technical functionalities insurers place on coverage to ensure sustainability. These may seem like hurdles, but in the majority of cases they are placed to ensure there is limited drug waste, appropriate drug use, and that fraud is mitigated.

There are also a number of clinical functionalities insurers can implement to verify that the drug spend is done appropriately. Formularies requiring the lowest cost generic, over-the-counter exclusions, prior authorizations, etc. are kept in place to make sure there is no misuse or unneeded cost incurred for therapy.

Both the technical and clinical requirements placed on prescription coverage in a company health benefits plan are a decision between the employer and employee. The overall components of the coverage are determined by the plan sponsor’s (employer's) decision on the plan. The more robust a plan, the more expensive per head it becomes. Because of this, many plan sponsors provide individual (employee) decision-making. The basic plan will be provided. In addition, if an individual wants more comprehensive coverage, that person will pay the difference out of pocket. Some employers provide flex plans, which further allow individuals to pay for any outstanding fees through that allocated amount.

Insurers remain up to date on what they cover, however, with the number of drugs entering the market expanding and the complexity of drug plan design growing, many times a product may not be covered. What can we do in this case? There are some instances where an exception for coverage will be granted. Supporting your patients to gain coverage can provide excellent patient experience and patient loyalty. Depending on the insurer and drug, you may need to fill out a form, write a letter from the patient, a letter from the prescriber, and letter from the pharmacy. There must be a compelling case for why an exception should be granted. This information will be reviewed by the insurer with a recommendation that will ultimately be passed on to the sponsor (employer) human resources to make a final decision.

Helping patients understand why and how things work as well as supporting them through the reimbursement process can provide relief for those with many concerns and result in possible coverage of necessary medications.

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