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One of the keystones of your group benefit plan is prescription drug coverage, which provides your employees with both useful everyday benefits and valuable protection against future medical conditions. But as drug costs continue to rise, prescription drug coverage is a benefit that must be managed closely if it is to remain viable.
Alberta Blue Cross is committed to working with you to control your drug plan costs, in the interest of ensuring the long-term viability of your Alberta Blue Cross group benefit plan.
To Alberta Blue Cross, administering your group’s drug benefit plan means more than simply paying claims. Our approach toward prescription drug plan management means working to maintain affordability for you while maximizing efficiency, convenience and flexibility for your employees. As drug costs continue to rise, effective plan management has become more important than ever. Here are some of the measures Alberta Blue Cross uses to help contain costs and provide better value for your benefit plan dollars.
Changes to biosimilar coverage and Maximum Allowable Cost (MAC) pricing
Alberta Health announces important changes to the coverage for biologic products and the maximum allowable cost (MAC) pricing for traditional drugs under Alberta government sponsored programs. Find out more about MAC pricing and biosimilar management options that are offered by Alberta Blue Cross for plan sponsors, and to learn how Alberta Blue Cross is committed to promoting drug plan sustainability.
Least Cost Alternative (LCA) pricing
The Alberta Blue Cross LCA price policy can save you and your employees money by substituting lower-priced products, where interchangeable drug products can be used. LCAs help keep your plan costs down—and mean your employees pay less out-of-pocket. Your employees receive the appropriate LCA automatically when they present their Alberta Blue Cross ID cards to their pharmacists. If your plan does not already pay drug benefits according to LCA pricing, you may want to consider switching.
Not every new drug product that comes onto the market is automatically added to your group plan. As drug manufacturers churn out hundreds of new products each year, the Alberta Blue Cross benefit review group—working together with our highly specialized Clinical Drug Services and Evaluation team—assesses the scientific, therapeutic and socio-economic value of each new product and determines whether or not it merits addition. In the case of some products—such as Viagra for sexual dysfunction, Propecia for hair loss or Xenical for weight control—coverage may be excluded.
Depending on your plan, certain drug products may only be considered for coverage by Special Authorization, a clinical process in which a physician requests coverage for a drug for a specific patient. Each request is processed according to specific criteria for coverage. If approved, a drug covered by Special Authorization for a patient is subject to the same deductible and co-payments as regular drug benefits. Special authorization requests are normally processed within three working days of Alberta Blue Cross receiving the request from the physician.
As you may know, pharmacies charge a “dispensing fee” for every prescription filled. Pharmacies are free to charge whatever they wish for the service. For Alberta Blue Cross drug plan participants, however, Alberta pharmacies agree to certain maximums. These maximums are outlined in the Alberta Blue Cross Pharmacy Agreement we have signed with individual Alberta pharmacies. Through our Pharmacy Agreements, your plan is guaranteed the lowest dispensing fee on prescriptions dispensed for your plan participants.
Audits of pharmacy service providers are undertaken by Alberta Blue Cross on behalf of our customers to ensure Alberta pharmacies are operating within the terms of their Alberta Blue Cross Pharmacy Agreement. Audits are used to ensure prescription drug pricing and claiming practices are consistent, valid and reasonable. Alberta Blue Cross recovers thousands of dollars each year through ongoing provider audit activities.
Drug-to-Drug Interaction Screening
Drug-to-drug interaction screening is a tool used by Alberta Blue Cross to automatically screen all direct-bill prescription drug claims for possible interactions with previously dispensed prescriptions. In cases where potential interactions are identified, the pharmacy receives immediate electronic notification. This protects your employees against potentially dangerous drug combinations, and saves money for your plan by reducing incidences of prescription drug wastage.
At the same time, there are many things that you as a group administrator can do to control your drug plan costs.
Foremost among these is educating your employees to be smart consumers. Do your employees understand the value of their prescription drug coverage? Some employees likely take their benefits for granted, and few are aware how much it really costs you to provide such benefits. But you can change that perception by informing your employees about the true value of their benefits. Remind your employees periodically about the value of their group plan, and the cost to your business to provide such benefits.
You can also advise your employees how to find better value. Here are a few suggestions:
Although Alberta pharmacies agree to dispensing fee maximums for Alberta Blue Cross plan participants, within these maximums dispensing fees can vary greatly, from 99 cents to over $19 depending on the cost of the drug product and at which pharmacy you shop. By comparing dispensing fees, your employees get the best price on their prescription drug purchases, and pay less out-of-pocket. This saves money for your employees and your plan.
In some circumstances, having a prescription filled for 100 days’ supply can also save on cost by reducing the number of times a dispensing fee is charged. Your employees can request 100 days’ supply from their doctor and pharmacist if they or a family member are on a maintenance drug schedule for long-term therapy.
Consider whether a prescription is necessary
Your employees should also know when not to ask for a prescription. If you’ve heard the saying “not all bugs need drugs,” you know that antibiotics need not be prescribed every time you are sick. Both viruses and bacteria cause infections, but antibiotics only work against bacteria. Most common respiratory infections are due to viruses, must run their course and are not aided by prescription drugs.
At the same time, thousands of products used to treat common ailments and minor illnesses are now available as “OTCs” (over-the-counter). In some cases, an effective remedy may be available to your employees without ever needing a prescription.
As well, not all illnesses are best treated with prescription medication. Conditions such as depression, for example, are estimated to cost Canadian workplaces over $8 billion per year in lost time and productivity. In many cases it is important for your employees to consult a physician, but by providing an Employee Assistance Program for your employees and encouraging them to use it as needed, your employees can also access confidential counselling that may provide a more effective long-term treatment than drug therapy.
If you would like to educate your employees about ways they can help ensure the continued viability of your plan, contact your Alberta Blue Cross group representative. We can provide you with communication support, including informative materials for duplication and distribution to your employees at your discretion.
You already know that you need to offer a group benefit plan to support your employees’ health—and as an incentive to attract and retain a qualified workforce. But there are a few options you can consider to limit your plan costs.
Depending on the size of your group, you may have options for the coverage levels, co-pays and benefit maximums your plan provides. Adjusting your co-pay structure, for example, can bring greater accountability to your employees through expanded cost sharing for prescriptions.
Adding a Health Spending Account (HSA) to your plan can also help you to contain costs. An HSA helps your employees pay for many health-related expenses that would not otherwise be covered, all in a tax-effective manner. And by managing their own benefit dollars, your employees become more aware of health care costs and become more responsible plan users. Alberta Blue Cross Health Spending Accounts are available to all groups.
Increasing utilization of prescription drugs by group plan participants is a big reason for rising plan costs. As our population ages, age-related illnesses such as diabetes and cardiovascular disease will drive costs even higher.
An ounce of prevention today can save your group plan thousands of dollars in future costs. By simply eating well, exercising regularly and giving up smoking, your employees can stay healthy—and take a big burden off both your plan and the health care system. Encouraging health and wellness brings you excellent return on investment, including reduced absenteeism due to illness and increased productivity due to better health. Do what you can to encourage a healthy work environment for your employees. Provide an on-site kitchen area where employees can eat rather than going out for fast food. Encourage employees to take a walk outdoors during breaks. Sponsor healthy recreation activities for your employees. Discourage smoking in the workplace, and support smoking cessation programs to help your employees kick the habit.
Many Alberta Blue Cross group plan sponsors are now implementing incentive programs to promote health and fitness. A program Alberta Blue Cross provides for its own employees, for example, provides partial reimbursement for fitness equipment as well as related activities ranging from aerobics classes and golfing green fees to weight loss programs and health club memberships. Investing in such a program not only provides a tangible benefit to your employees, but encourages them to get active—and helps them maintain their health.