Public/Third Party Payers and Prescription Drug Plans

Question 1

What is the Alberta Health Care Insurance Plan?

Answer 1

• Provinces are granted authority to manage their own health care, based on the Canada Health Act
• Covers hospitalization, medically necessary surgery, physician visits, lab services, health aspects of LTC, home care, and ambulatory care, prescription drugs for in-patients

Question 2

What are the similarities between publicly and privately funded health care plans?

Answer 2

• Both have drug benefit list
• Benefits are defined (“special” benefits for public; “coverage” for private)
• Both typically follow provincial drug formularies
• Budget management
• Pricing controls (for provincial)

Question 3

What are the main PUBLIC differences in drug coverage?

Answer 3

• Drug benefits are informed by the National Common Drug Review (Evidence-based review - considers relative efficacy and costs to current meds; pan-Canadian initiatives for alignment and consistency)
• Funding (some funding is collected from participating members in form of premiums, rest is payed by taxpayers)

Question 4

What are the main PRIVATE differences in drug coverage?

Answer 4

• Drug benefits are informed by Health Canada’s granting of a Notice of Compliance (NOC) (listing informed by new drugs coming to market and provincial formularies; Health Canada only looks at safety and effectiveness)
• Funding (all funding is collected from participating members in the form of premiums and/or employer contributions)
• Pre-existing health conditions not usually funded

Question 5

What is the role of Alberta Blue Cross in drug plans?

Answer 5

• Private, not-for-profit corporation contracted by government of Alberta to process claims, provide administration and research support for drugs to come on benefit list, administer special authorizations process

Question 6

Who is involved in adding drugs to the ADBL?

Answer 6

• Drug manufacturers
• Health Canada (NOC - safety, efficacy, quality - essentially ensuring drug is safe to sell in Canada)
• Canadian agency for drugs and technologies in health (CADTH) and Common Drug Review Process (provinces and territories get together to review merits of new drugs relative to other treatments and make recommendations for public coverage)
• Alberta Expert Committee on Drug Evaluation and Therapeutics
• Alberta Blue Cross
• Alberta Health

Question 7

How do brand drugs get on ADBL?

Answer 7

• Drug manufacturer makes a submission –> Canadian Drug Review –> Alberta Blue Cross researches to check if drug has NOC and is identified for review
• Expert committees review based on therapeutic value and cost effectiveness
• Alberta Health makes the final decision and applies price policy (does drug meet price threshold) to determine if drug can become benefit

Question 8

What are the 5 aspects of drug plan design?

Answer 8

1. Need/issue (Wh Qs, plus other questions to consider)
2. Eligibility (Wh Qs, other questions)
3. Coverage criteria (what drugs, what services, what rationale for coverage, Wh)
4. Payment/Claims (which administration, how do Albertans pay, how will pharmacies pay, electronic or paper system, which pharmacies, coordination of benefits, CPhA Claim Standard, how much paid, other Qs)
5. Budget management (how to control costs, lack of funds, other budget concerns)