Providing targeted support to the 20% of benefit plan members who need help


Maggie is a marketing manager who has worked with the same company for 12 years and has contributed greatly to its success. Lately, though, she has been calling in sick a lot more often and seems tired and not quite with it when she is at work. The VP she reports to has asked HR to set up a meeting with her.

For those who know her well, Maggie’s situation isn’t surprising. Although she disguises her health challenges among people she isn’t close to, Maggie has nine chronic conditions. One is severe and potentially disabling (multiple sclerosis), three are also potentially life-threatening (high cholesterol, high blood pressure and pre-diabetes-level blood glucose) and three dramatically reduce the quality of her life and work (depression, chronic bladder infections and insomnia).

She sees four different doctors, and only her very busy GP has any insight into the treatments recommended by the other physicians. As directed, Maggie takes 10 different drugs each day, as well as a couple of supplements. She fills some of her prescriptions at the tiny drug store in the medical building where one of her specialists is located, some at the large chain pharmacy by her office and some at the grocery store pharmacy near her home. Because she is not always near the right pharmacy when a prescription runs low, she often misses days and sometimes even weeks of some medications. She thinks that one of her prescriptions may be causing the dizzy spells she’s been experiencing, so she’s made an appointment with the specialist who prescribed them, but he isn’t available for three months.

Maggie does her best to exercise and eat right because she knows it makes a difference, but anxiety keeps her awake at night, so a lot of the time, she’s so tired at the end of the day that take-out and Netflix are all she can manage. Her benefit plan pays for 80% of her drug costs (more than $12,000 each year), but Maggie worries a lot about the $3,000 she pays that would otherwise go into her RRSP for her upcoming retirement. She does her best, but her health continues to worsen. She’s wondering how long it will be before she has no choice but to go on long-term disability.

Read: Patient Safety Week – Asking these 5 questions about your prescriptions could save your life

Her friend Dennis is in a similar situation. Dennis has diabetes along with many of the conditions associated with it, including depression, neuropathy (terrible pain in his feet) and heart disease. Dennis has three physicians and takes nine medications each day. Yet he just can’t keep his blood glucose at healthy levels, so his health continues to decline.

Maggie and Dennis are both fictitious characters. But together, their experiences reflect that of 20% of the members of Canada’s health benefit plans—members whose medications comprise almost 80% of total plan spending. Without help, members like these often pay more than necessary for their medications; they don’t know where to turn when they have urgent questions. More than 49% have at least one medication they are not taking as directed.

Read: How a comprehensively managed prescription drug plan helps control plan spending

But a number of leading plan sponsors are turning the tide, making it possible for these members to thrive while better controlling their own costs. With a comprehensively managed plan in place, members like Maggie have convenient phone and email access to a drug expert specializing in the treatment of their condition, along with a pharmacy team that can connect with any of their doctors when issues arise. They can centralize their prescriptions and have them delivered to their home or office before they run out. Members like Maggie and Dennis have help identifying the most effective drugs at the right time, before ordering a new prescription, resulting in significant potential savings and improved efficacy and adherence.

Most importantly, they no longer feel alone in their efforts to coordinate their care, save money and improve their health.