Prescription drug benefit plans

At Wawanesa, we understand the sustainability of your benefit plan is important to you.

Prescription drug costs continue to increase every year and make up a significant portion of health plan claims.

We offer plan design options to help keep your benefit plan effective and affordable. Our platform of drug cost management can help protect access to drugs for Plan Members while ensuring benefit plans are sustainable for Plan Sponsors.

Built-In Fundamentals

Our prescription drug benefit plans consist of some fundamentals that are included on all plans.

Prior Authorization – Ensures that Plan Members who need high-cost drugs have met all required criteria (such as trying first-course drug therapies before second course treatments).

Biologics Management Policy – Biologic drugs are produced using living organisms and often are high-cost drugs that treat specific conditions. Our policy ensures that biologics are reviewed for effectiveness, safety, cost and provincial drug formulary status. We ensure the most cost-effective biologic is eligible before moving to nonpreferred options.

Biosimilar Policy – When a plan member applies for coverage for a biologic drug, they will be approved for the biosimilar where applicable. There is no coverage for the originator drug under the plan except in very rare situations.

Other Policies – We offer access to medications Plan Members need in the most cost-effective manner.

Examples of our policies and programs include:

• Medication fill limits
• National drug pricing program
• Compound drug management
• Fraud management
• Concurrent drug utilization review
• Product Listing Agreements
• Maximum allowable cost
• Provincial integration
• Fill too soon limits
• Compliance package management
• Migraine/narcotic pain management programs

Plan Design Customization:

Plan Sponsors can customize the plan to meet their unique needs by choosing coinsurance, deductibles, and maximums.

Other plan design options are available to help further control costs through formularies, other included drugs, and generic substitution/lowest cost alternatives.

Formulary options:

A formulary is the list of drugs that your plan will cover. We offer multiple formulary options that allow Plan Sponsors to align their drug management philosophy to the list of drugs covered under the benefit plan.

An Open Formulary includes most drugs approved by Health Canada. Every new drug is reviewed prior to adding them to the formulary to ensure that they have therapeutic value over existing drugs already covered. This is a more traditional offering that provides a more robust list of covered drugs. Some drugs are added on a special authorization or individual consideration basis meaning that certain medical criteria must be met before an individual is eligible for payment for that drug.

A Provincial Formulary mimics the drugs covered by each provincial plan and the list of covered drugs will vary by province based on the Plan Member’s province of residence. This formulary is more restrictive than an Open Formulary. Individuals who are prescribed a drug not listed on their provincial formulary will either need to discuss other options of medications with their doctor or pay for the drugs out of pocket.

Options for other drugs:

Other kinds of drugs can be added as an option. This can include drugs such as smoking cessation, erectile dysfunction, fertility drugs, and vaccines.

Generic drug and lowest cost alternate options:

Not all drugs are the same, but some drugs may be just as effective as other drugs to treat the same conditions and at a lower cost.

Pharmaceutical companies can produce generic drugs after the patent on the brand name drug has expired. Health Canada regulates all generic drugs, and they must include the same medicinal ingredients as the brand name version and meet the same requirements to ensure it is equally effective as the brand name drug.

Generic drugs can cost significantly less than the brand name equivalent and is a way that can save your plan money without a substantial impact to Plan Members.

In addition, sometimes there are lower cost alternate drugs. These drugs may not be the generic version of a drug, but instead may be a different chemical compound which can treat the condition with the same outcome.

Three options for drug management for generic substitution and lowest cost alternative exist.

Name Brand - If the brand name is prescribed and physician or Plan Member requests no substitution, the plan member will be reimbursed based on the brand name drug[1].

Lowest Cost Alternative (LCA) - If the brand name is prescribed, and the physician requests no substitution, the plan member will be reimbursed based on the brand name drug cost[1]. If the plan member requests no substitution, the plan member will be reimbursed based on the lowest cost alternative[1].

Mandatory Lowest Cost Alternative (MLCA) - If the brand name is prescribed, and either the physician OR plan member request no substitution, the plan member will be reimbursed based on the lowest cost alternative[1].

If a claimant cannot take the LCA drug due to an adverse reaction, the physician can complete an Adverse Drug Reaction form for the member and the name brand drug will be considered.

1. Based on the usual & customary (U&C) cost↩