Practical considerations for coverage of medical cannabis
Clinical evidence and consumer utilization—as well as the possibility of distribution through retail pharmacy—increasingly suggest that the coverage of medical cannabis under private benefit plans is simply a matter of time. However, as a therapeutic option medical cannabis is very much in a league of its own, which raises a host of practical issues.
“This is an incredibly dynamic and evolving space. For a lot of people, that spells uncertainty,” Jason Kennedy, director, operations, at TELUS Health, told attendees at the Face to Face Drug Plan Management conference in Toronto in early December. He and Matt Gaudry, director of product support and management, customer experience and marketing at Great-West Life, co-presented on how to address the practical considerations surrounding coverage of medical cannabis.
“While it’s true that we don’t yet have all the answers, we have to start somewhere as an industry, then continuously iterate and improve. It is only through experience that we will gradually be able to move the market to a standard,” added Kennedy.
As a national adjudicator, TELUS Health is planning for a future where medical cannabis could be a standard benefit under the drug plan, taking into account that pharmacy could become a major distribution channel. “It is a prudent course of action to plan for this, and we are building a structure so that we can easily pivot to adjudication through pharmacy if that is where distribution goes,” says Kennedy.
While coverage is also possible under health spending accounts and extended health benefits, a drug plan provides additional advantages in the longer term. “We can have more control and better data. The functionalities of existing pharmacy adjudication engines allow for a lot of flexible, mature options to help manage the experience and risk,” says Kennedy. To that end, he adds, “what we’re trying to do from a standards point of view is work with licenced cannabis producers to have them obtain pseudo drug information numbers, or PINs, for their products, since right now these products don’t have DINS [drug information numbers].”
During his presentation, Kennedy focussed on three key practical considerations for plan sponsors and benefits advisors: availability, cost containment controls, and analysis of the impact on the plan.
Availability of product can appear overwhelming at first, given that there are more than 130 licenced producers in Canada, each with multiple medical cannabis products, none of which come with monographs that spell out approved indications. Preferred licenced-producer relationships are recommended, to develop a product list that links specific strains to the treatment of specific conditions.
When it comes to cost containment, prior authorization and annual maximums will ease plan sponsors’ concerns about entering a market that is still very much in early days. Prior authorization can limit coverage to the conditions where clinical evidence is strongest; for example, nausea and vomiting due to chemotherapy; spasticity due to multiple sclerosis; and neuropathic pain. Prior authorization can also stipulate that medical cannabis is a last line of therapy, for use after conventional therapies have proven ineffective.
Plan sponsors and benefits consultants can work with carriers to estimate the budget impact for plan sponsors. “With the first two practical considerations in place, we can arrive at the potential incremental costs—keeping in mind that, over time, we hope to see some offsetting costs in other therapeutic and benefit areas,” says Kennedy.