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New Contract Provisions
The prescription drug landscape is evolving. The emergence of new, high-cost specialty medications and biologic treatments, combined with increased provincial drug reform for generic drugs, has introduced new challenges for benefit plans.
Many plan sponsors are looking for solutions to maintain their benefits offering in the face of rising costs and demands. Great-West Life is taking a proactive approach to prescription drug management to help meet these needs by implementing new contract provisions to help maintain benefit plan sustainability. The following is a brief description of some of the more significant new provisions. What’s NeW?
• enhanced Generic substitution: Many popular medications will be coming off patent in the next few
years, so providing a lower cost interchangeable “generic” drug substitution provision for plans will become increasingly important.
Currently, it’s not uncommon for a physician to prescribe a brand name drug such as “Lipitor” instead of its generic equivalent “Atorvastatin Calcium”. Yet, according to Great-West’s data, the price for generic Atorvastatin is approximately one-third of the brand price. Enhanced Generic Substitution for drug card plans, unless a plan member submits a Request for Brand Name Drug Coverage form indicating why a prescribed drug cannot be substituted, benefits will be based on the cost of the lowest priced interchangeable drug that has the same medicinal ingredient. A plan member can still choose to purchase the prescribed drug and pay the cost difference.
• health Case Management is a program for Great-West plans where a claim has been made for
certain services and supplies – with an initial focus on new claims for specific medications requiring prior authorization. Through Health Case Management, Great-West will work with a patient and his or her physician to gain a greater understanding of the treatment plan, identify opportunities for education and monitor treatment plan adherence, such as taking medication correctly.
This medical coordination approach is similar to other areas where Great-West manages benefits, such as disability case management. Great-West sees Health Case Management as a significant opportunity to help improve patient outcomes and enhance service through benefit plan management. • Prior authorization: Great-West has formalized its prior authorization process by clarifying its information
requirements. This will help to more proactively manage claims for certain covered services and supplies and support appropriate treatment guidelines, in some cases leading to Health Case Management. Great-West can also direct a plan member to a designated provider in order to improve the patient experience while also either reducing costs or ensuring Health Case Management programs are being followed.
• Patient assistance Programs: Some manufacturers and distributors, particularly manufacturers of biologic
therapies, provide supporting patient assistance programs. Some of these programs include education, training, therapy adherence and financial support. Under new contract provisions, Great-West may require plan members to apply for and participate in any patient assistance program to which they may be entitled. • Coverage While in hospital: In order to further protect against rising drug costs and maintain the
intended separation between private and public funding, new contract wording will clarify that drugs administered in a hospital to an in-patient are not eligible for reimbursement by Great-West.
We’re looking forward to working with you and providing innovative prescription drug and health benefit solutions to help meet your needs now and in the future.
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The Great-West Life Assurance Company, all rights reserved. Any modification of this document without the express written consent of Great-West Life is strictly prohibited.
P ublication of © rtgin al D o cu m e n t0 L A N C A S H I R E A N D C H E S H I R E . J o h n P a u l R y l a n d s , F . S . A . , Highfields, B i d s t o n R o a d , Birkenhead, Sir G e o r g e J. A r m v t a g e , Bart., D .L ., F .S.A., Kirklees Park, B rig- Lieut.-C ol . H e n r y F i s h w i c k , F.S.A ., T he Heights, Rochdale, Vice- H e n r y B r i e r l