Meet Brad. Brad just turned 56 and is a mid-level manager with a tech firm in Southwestern Ontario. He’s always been relatively healthy, and he believes that he has an excellent drug plan. But he does have a family history of type 2 diabetes, and he worries what the health and cost implications would be if he had to take medication on an ongoing basis.
Like many Canadians, Brad has had access to a prescription drug plan, but has never needed to use it, except for the occasional antibiotic. When he was diagnosed with type 2 diabetes recently, he knew that it was a serious condition, but also knew that it could be managed with diet, exercise, and medication if necessary.
When Brad was diagnosed, his family doctor prescribed a new drug called Januvia®. Although Brad didn’t know it at the time, his workplace drug plan is what is called a comprehensively managed plan, meaning that the plan proactively guides patients and their doctors to the most cost-effective therapies, leading to lower costs and healthier outcomes.
Brad’s drug plan could cover Januvia® in some cases, but the plan includes a step therapy program that requires patients to try a drug called metformin first. This aligns with Diabetes Canada guidelines that point to metformin as the first choice for people with type 2 diabetes based on abundant data on its durability and long history of safety. This was flagged at the pharmacy and the pharmacist reached out to Brad’s doctor to discuss changing the prescription. With Brad taking medication on an ongoing basis, the switch from Januvia® to metformin not only saves the drug plan about $1,000 a year, it also saves Brad about $200.
Another element of a comprehensively managed drug plan is patient health management services, meaning that support is available if patients have concerns about their medication. In the case of Brad’s drug plan, members have access to a Therapeutic Resource Centre (TRC) that includes pharmacists specializing in a number of different conditions. Brad was concerned about switching therapies. He thought at first that he might be getting a less effective medication, just to cut costs. He expressed this concern, and subsequently got a call from one of the TRC pharmacists specializing in diabetes, who explained the clinical rationale behind the therapeutic switch, and put Brad’s mind at ease.
After talking to Brad and looking over his drug claim history, the TRC pharmacist took the opportunity to alert Brad to the potential benefits of other medications that could help to reduce risks associated with diabetes. Brad discussed this with his doctor, who prescribed additional medications to control high cholesterol and high blood pressure. Although Brad was never diagnosed with these problems, Diabetes Canada now recommends this preventive treatment for individuals his age because of the clinical evidence showing that they can be protective of kidney, heart and circulatory function and can help prevent eye disease.
Brad’s drug plan also includes an incentive program that encourages plan members to fill their ongoing prescriptions through a preferred pharmacy network that delivers 90 days’ supply at a time, offers auto refills and even reaches out to prescribing doctors for prescription renewals. Brad signed up and is now getting all of his ongoing medications delivered to his home. The auto refill option and notifications when he needs a new prescription have really helped Brad stay on track with all his medications, and his doctor is pleased with how he is managing his diabetes.
Brad didn’t know he was part of a comprehensively managed drug plan, but when his diabetes diagnosis presented him with a daunting healthcare challenge, the plan sprung into action, and helped deliver the best possible health outcome at the lowest cost. This helps Brad in three ways: It helps him stay healthier, it saves him money, and it makes his workplace drug plan more affordable, meaning it will be sustainable for years to come.
This case study is taken from Express Scripts Canada’s Prescription Drug Trend Report for 2017. Learn more about comprehensively managed plans and prescription drug spending trends by reading the report. The name of the individual in the case study has been changed to protect his privacy.