Choosing the right plan

Your choices today can impact the future.Choosing the right health and drug benefit plan for your organization promotes a healthy workforce, increases employee satisfaction and contributes to your bottom line.

There are many factors to consider when selecting a plan, including your goals for the plan, the number of employees, the needs of your workforce, and your budget. Most employers purchase benefits with the goal of providing plan members access to the most appropriate and timely treatments.

To manage budgets, employers may consider adopting measures to reduce costs, however, most of these measures will restrict employee access to needed medicines. Examples include influencing the choice of therapy, delaying or denying therapy, or influencing the method of access (case management, PPNs, etc.). Other measures impose greater cost-sharing for employees by way of higher deductibles, premiums, or co-payment amounts. Limiting the amount of benefits payable to employees, such as annual or lifetime caps for drugs, can save money in the short term but is not a long term solution.

It is important to know the implications of all these measures for your employees and how they impact access to the right treatment at the right time. Which could have a negative impact on your employees’ health, which in turn carries a hidden cost: lower employee productivity and an impact to your bottom line.

Employers need to weigh the costs vs. benefits when providing comprehensive benefit plans that will attract and retain the best employees. As the complexity of plans increase, it is important to work with a trusted resource to help you understand the short-term and long-term impacts to employees and your business.

In today’s environment of providing high quality health benefits while managing your plan costs, “plan hygiene” is becoming a priority for many employers. Plan hygiene refers to the overall health and design of your plan. There may be simple options to improve your overall plan costs while having minimal impact on member access to medications. Working with your provider to limit drug mark ups, dispensing fees, and the frequency of refills for chronic medications are just a few examples.

Plan design types and their impact on Employee Access to Therapy
Each check represents negative impact on access to the plan member
Drug Plan Feature Delay Therapy Increases
Financial Burden
Additional Administrative Burden/Steps Sub-Optimal
Therapy
Deny Access
Preferred Pharmacy Network
Deductibles Co-Payments
Prior Authorization / special authorization
Generic Substitution (except “Do not Substitute”)
Mandatory Generic Pricing
Step Therapy
Maximum Allowable Cost
Therapeutic substitution
Tiered Formulary
Managed Formulary Plans
Maximum Limits/caps
Annual/Lifetime
Provincial Formulary Mimic