Drug Plan Management Solutions

A drug plan is an essential part of any comprehensive benefits package, for both you and your plan members. A 2005 survey¹ of 1,500 Canadians with group healthcare coverage revealed that plan members value their drug plan more than any other group benefit. Drug plans are also the most frequently used healthcare benefit—used by more than two thirds of plan members. ²

Prescription drugs are the fastest rising cost component of group healthcare claims. Cut-backs in government-sponsored plans, Canada’s aging population and the introduction of new, more expensive drugs are adding up to increased costs for you and your plan members.

We offer a range of drug plan options that can be tailored to suit your organization's needs, allowing you to better manage the rising cost of prescription drugs while providing your plan members with the coverage they need. We can help you keep your drug plan affordable for you and your plan members.

We can help you manage your drug plan in two ways – by using drug formularies, and through other methods of cost-containment.

Managing your drug plan with formularies

Whether your plan design is comprehensive or managed, and whether your claims payment choice is reimbursement or electronic, we offer a wide variety of formularies to suit your needs.

A formulary is a list of drugs the benefits plan will cover, out of the thousands of prescription and non-prescription drugs on the market today. There are many types of formularies, but the overall goal of each one is to control the eligibility of drugs, and therefore help manage drug costs by either:

• Adding new drugs only after their therapeutic value and cost effectiveness have been proven, or
• Allowing only generic drugs, or
• Following the guidelines set by provincial governments.

Two-tiered plans

A two-tiered drug plan design allows you to cover two formularies at two different levels of reimbursement. A tier-one managed formulary with a higher coinsurance can be supplemented by a more comprehensive formulary at a lower coinsurance level. This allows your plan to maintain broad drug coverage, while still lowering overall costs.

Managing your drug plan with cost-containment options

We offer a number of plan design options to help you manage your healthcare plan costs. Let us help you determine which of these solutions fit your needs.

Generic substitution

• Cost reimbursement to the value of the generic equivalent of a drug, regardless of what has been prescribed, unless the physician indicates ‘no substitution’ on the prescription

Per-prescription deductibles

• The amount the plan member must pay for each prescription drug claimed
• It can be set to a specific amount, or equal to the dispensing fee portion of the drug

Coinsurance

• A percentage amount the plan will pay for eligible prescriptions after any deductibles have been met

Dispensing fee limits

• Coverage to the maximum amount of the fee pharmacies charge to cover their business expenses
• Fees vary by pharmacy, province and region
• This option is not available in Quebec

Drug maximums

• The maximum amount the plan will reimburse for prescription drug coverage per person, per calendar year
• Maximums can be set at a specified amount per year, or can be unlimited
• This option is not available in Quebec

Speak with a Great-West group benefits representative to learn more about these and other options, and how they might impact your benefits plan costs.

A note to plan sponsors in Quebec

The Quebec government has a public drug plan that covers anyone who is not eligible for coverage under a private plan. This plan is administered by the Régie de l’Assurance Maladie du Québec (RAMQ).

The law in Quebec also requires private drug plans to provide equivalent or better coverage than the public plan. Plan sponsors in Quebec are limited in how much they can alter their drug coverage, since they must ensure it conforms to RAMQ.

^1. The 2005 Sanofi-Aventis Healthcare Survey on Canadians and Their Group Healthcare Benefits, conducted by Ipsos-Reid

^2. Great-West Life data