Pacific Blue Cross
• Pacific Blue Cross is a not-for-profit organization
• our resources are used to serve stakeholders, not
stockholders.
• financial surpluses are reinvested into the business
for the current and future benefit of our members.
• Pacific Blue Cross and BC Life are represented by
CUPE local 1816.
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Underwriting
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The contract is underwritten on an Administrative
Services Only (ASO) basis.
An ASO plan is a self-funded plan. The contract holder
is exclusively responsible for all financial aspects of the
group benefit plan.
The carrier handles the claims adjudication and payment
process and is paid a percentage of paid claims for their
work.
Underwriting - Insured
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Pay a set rate
regardless of usage.
Underwriting - ASO
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Pay for actual usage.
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Prescription Drug Benefit Changes
Pay Direct Drug Card
• increased claim submissions due to
• “forgotten claims”
• additional purchases
New coverage
• sexual dysfunction prescription drugs
• contraceptive prescription drugs
Coverage changes
• Blue Rx managed formulary
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Blue Rx Managed Formulary
Drugs that are more expensive without offering better treatment outcomes are not covered or are only covered if first line therapy has been tried and failed.
Most new drugs have no incremental therapeutic value
but are usually the most costly in their respective
therapeutic class.
*In 2011, there were 109 New Brand Drugs
1% breakthrough
5% substantial improvement
*PMPRB Annual Report 2011, Appendix 2, Government of Canada
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Single Source Brands Multiple Source Brands
& Generics
Limited Benefit High Cost
Blue Rx
Blue Rx Managed Formulary - Categories
• Innovator Brand
• No generics available
• Usually still under patent protection
• e.g. Lyrica™
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Single Source Brands
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• Brand drug for which patent has expired
• Generic versions are available
• e.g. Lipitor™
Multiple Source Brands & Generics
Multiple Source Brands
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• Same active ingredients
• Same dosage form
• Same strength
• Same conditions of use
• Different inactive ingredients but must have been proved safe
Generics
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Generic Drugs – Health Canada
Reproduced with permission from the Minister of Health, 2013
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Generic Drugs – Interchangeability
Section 25.91 of the Health Professions Act allows a British Columbia Pharmacist to dispense an interchangeable drug (generic).
Generic dispensing frequently happens without the patient knowing.
In 2012, a study of the most common drugs prescribed to BCTF members showed generics were dispensed 82% to 96% of the time.
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• 2nd and 3rd line treatments for which a less expensive alternative is available
• Requires Prior Approval
• Categories:
• Diabetes
• Ulcer Therapy
• Asthma / COPD
• Acne
• Anticoagulation
Limited Benefit
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• Drugs that have an annual cost of $1,500 or more per year
• Require PharmaCare Special Authority to access government funding
High Cost
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Single Source Brands Multiple Source Brands
& Generics
Limited Benefit
High Cost
Blue Rx
Blue Rx Cost Containment
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Pharmacy Services Fees – all categories
Maximum Dispensing Fee and Mark up are limited to Reasonable and Customary amounts as determined by an agreement reached between BC PharmaCare, the BC Pharmacy Association and the Canadian Association of Chain Drug Stores.
Pharmacy Compass is an online tool developed by Pacific Blue Cross that helps you compare the price at different pharmacy locations across British Columbia.
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www.pharmacycompass.ca
• Maximum eligible cost is the Manufacturer’s List Price.
• For 21 drugs the maximum eligible cost is the reference drug price (limited benefit).
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Single Source Brands
Ingredient Cost Limit
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• If there are chemical equivalents, the maximum eligible cost is the lowest cost of all the chemical equivalents.
• If there are no chemical equivalents, the maximum eligible cost is the Manufacturer’s List Price.
Multiple Source Brands & Generics
Ingredient Cost Limit
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Limited Benefit
Prescribed drug: Januvia
$3.00 per day
Covered drug: Metformin
$0.20 to $0.50 per day
Payment reduced to covered drug
Physician completes form (specialist exemptions)
PBC evaluates the submission
If approved, payment for prescribed drug
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Payment declined
Physician completes form (specialist exemptions)
PharmaCare evaluates the submission
If approved, payment for prescribed drug
High Cost
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Generic Cost Containment
• Effective April 1, 2013
• generic drugs in BC will be priced at 25% of the equivalent brand drug.
• As announced by The Council of the Federation, all provinces and territories (except for Quebec) have agreed to establish a price for the 6 most common generic drugs at 18% of the equivalent brand drug.
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Generic Cost Containment
Prior Coverage Blue Rx
Lipitor, 20mg Atorvastatin, 20 mg @ 18%
Monthly drug cost: $70.80 Monthly drug cost: $12.74
Plan pays (80%): $56.64 Plan pays (80%): $10.19
Member pays: $14.16 Member pays: $2.55
Member saves: $ 11.61
Plan saves: $46.45
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Special Authority Cost Containment
Prior Coverage Blue Rx
Remicade Remicade
Est. annual cost: $19,000 Est. annual cost: $19,000
No Special Authority approval Special Authority approval
Plan pays: ~ $19,000 Plan pays: ~ $4,000*
PharmaCare pays: ~$15,000
Plan saves: ~$15,000
* Assumes $100,000 annual family income and 100% PharmaCare
coverage after 4% of income.
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Resource Centre –
www.pac.bluecross.ca/teachers
Thank you