A reimbursement balancing act

The arrival of biosimilars in Canada has ushered in a variety of new considerations around the issue of reimbursement. Central to this discussion is how public healthcare systems and private insurance companies handle the reimbursement of these new therapeutic options

First: What is the difference between innovator biologics and biosimilars? As the name suggests, a biosimilar medication is similar but not identical to the originator biologic it is intended to replicate. Both of these types of large-molecule medications are created from living cell lines, so no two medicines are exactly the same. As such, the small differences between products are inevitable and may cause unexpected outcomes when a patient is switched from the originator biologic to the biosimilar or vice versa.

What does this have to do with reimbursement?

Biosimilar medications tend to be less expensive than their brand name originator biologic counterparts. Private payers (such as private insurance companies that offer third-party insurance), and public payers (provincial/territorial drug benefit programs or federal programs for certain groups) need to make important decisions around reimbursement of originator biologics vs. biosimilars. This means balancing biosimilars’ cost effectiveness and value while remaining focused on patient and provider needs.

What’s the issue? And what should I do?

Health Canada recommends that a decision to switch a patient being treated with an originator biologic drug to a biosimilar should be made by the treating physician in consultation with the patient, and taking into account available clinical evidence and jurisdictional policies.

If you’re concerned about your company’s insurance coverage, you may want to speak with your human resources representative.

It’s important to remember that your health information is personal and confidential; so if you choose to reach out to your employer, it’s important to be mindful about disclosing detailed health information about your condition and treatments.

If you are a benefits consultant, your HR contacts may not know that this is an issue that some employees face. You can have a conversation with them to help understand the nuance of biologic reimbursement.

Here is a discussion guide for employees speaking to human resources about this issue.

Employee to HR Discussion Guide / Checklist

Discussion points employees can raise with HR departments:

  1. Identify the Challenge: Identify that insurance companies may, at some point, change the way they reimburse biologics/biosimilars; so the employee is asking that HR clarify the policy and advocate that both innovator brand name biologics and biosimilars be eligible for reimbursement.
  2. Explain the Issue: Health Canada recommends that a decision to switch a patient being treated with a brand name originator biologic drug to a biosimilar should be made by the treating physician in consultation with the patient, and taking into account available clinical evidence and jurisdictional policies.
  3. Note the potential benefits of the medication: Based on your doctor’s assessment, the treatment prescribed is the best course of therapy and essential for one’s optimal health and wellbeing.
  4. Understand the policy: What is the company’s coverage policy regarding biologic / biosimilars reimbursement?If you are a new biologic patient — someone who has never received the specific biologic drug being prescribed — and that originator biologic drug has a biosimilar available here are some additional questions you may want to consider asking:
    • Will the company’s plan allow you, the patient, access to the brand name originator biologic?
    • Will the company’s plan require you to try the biosimilar?
      • If you, the patient, are required to try the biosimilar, is it because of the lower cost of the biosimilar?
      • Are you, the patient, able to choose the brand name originator biologic drug and pay the difference in cost between the biologic and biosimilar?

    If you are currently taking an originator biologic drug that has a biosimilar available:

    • Will you continue to be reimbursed for the originator biologic you have been taking, even though a lower cost biosimilar is available?
    • Will your plan require you to switch from the biologic to the lower cost biosimilar alternative?
  5. Be Proactive: Note that you might be seeking your insurance company’s support for your doctor’s decision by calling or writing them and requesting access to the medication (an exception or “extra-contractual coverage”). And to copy you on that letter if they do so.
  • Remember that your health information is personal and confidential; so it’s best to be mindful about disclosing detailed health information about your condition and treatments.

Download a printable version of this discussion guide here

Benefits Consultant to HR Discussion Guide / Checklist

Discussion points benefits consultants can raise with HR departments:

Issue: In deciding what products to include in a drug plan – public or private – payers make an assessment of the “value” offered by a product. Understanding what benefits a particular customer values and using the right customized lens for the job will lead to the best decisions for plan sponsors and members alike.

  1. Identify the Challenge: Identify that insurance companies may, at some point, change the way they reimburse biologics/biosimilars; Probe the intent of the employee drug plan and ultimately the consultant may be asking that the employer plan to make an exception (called “extra-contractual coverage) and advocate that this be considered on a case-by-case basis.
  2. Explain the Issue: Health Canada recommends that a decision to switch a patient being treated with an innovator brand name biologic drug to a biosimilar should be made by the treating physician in consultation with the patient, and taking into account available clinical evidence and jurisdictional policies.
  3. Probe the intent of the employee drug plan:
    • What are your company’s objectives for the employee drug plan? Keeping employees happy healthy and productive? Retaining top talent?
    • When structuring you company’s employee drug plan, what are some of the factors that are considered and prioritized? Cost? Impact on families and caregivers? Workplace productivity? How attractive a benefits package is?
    • Do you think employees would want and should have a drug plan that covers the exact drug that their physician prescribes?
  4. Make your request: Would the company be interested in working with the insurance company to develop a plan for medication coverage that meets the current and furture needs of its employees? As an employer, you may have the option to change your plan, or you may have the option of making an exception for medications needed by your employees.

Download a printable version of this discussion guide here.

Learn more about switching here.

If you think the medication prescribed by your physician is not covered by your benefits provider, speak to your HR representative.

After reading this article, are you more likely to speak to your Human Resources department about reimbursement?

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