PRESCRIPTION DRUG TREND REPORT - EXPRESS SCRIPTS CANADA - Express Scripts Canada, 2019. All Rights Reserved.
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EXPRESS SCRIPTS CANADA
PRESCRIPTION
DRUG TREND REPORT
©Express Scripts Canada, 2019. All Rights Reserved.
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E X E CU T I V E S U M M A R Y 03
CON T EN T S
M E T H O DO L OGY
A N D T E R MINO L OGY 09
• D RU G T RE N D RE P O R T M E T H O D O LO GY 11
S E C T ION 1 13
IN SIG H T S IN TO CH A L L EN G ES
A N D O P P ORT U N I T IES 14
• D RU G S P E N D P E R CL A I M A N T 15
• S U P P O R T A N D S O L U T I O N S – T H E P RI N CI P L E S
O F A P P LY I N G D RU G BE N E F I T S O L U T I O N S 22
• P AT I E N T I N S I G H T S 24
S E C T ION 2 35
A LO O K AT T HE OV ER A L L
DRUG T REN D FOR 2018 36
• OV E R A L L T RE N D I N 2018 37
• T R A DI T I O N A L D RU G T RE N D OV E RV I E W 38
• S P ECI A LT Y D RU G T RE N D OV E RV I E W 39
• TO P T E N M E DI C AT I O N S BY S P E N DI N G 40
• TO P T E N T H E R A P Y CL A S S E S - I N S I G H T S FO R 2018 41
• OT H E R N OTA BL E T H E R A P Y CL A S S E S 54
S E C T ION 3 57
N AT IO N A L A N D
PROV IN CI A L OV ERV IE W 58
• N OT E W O R T H Y N AT I O N A L D E V E LO P M E N T S 59
• P ROV I N CI A L OV E RV I E W 61
S E C T ION 4 67
PH A RM ACY L A N DSCA PE 68
• U P DAT E O N PAT E N T E X P I R AT I O N S 69
• 2018 BI O S I M I L A R S I N T RO D U C T I O N 70
• A LO O K FO R W A RD 71
• PIPELINE 76
A P P E N DI X 81
• 2018 N E W BR A N D A P P ROVA L S 82
• 2018 N E W I N DI C AT I O N A P P ROVA L S 84
• D RU G S CU RRE N T LY U N D E R RE V I E W BY H E A LT H C A N A DA
FO R N E W BR A N D A P P ROVA L S 86
• D RU G S CU RRE N T LY U N D E R RE V I E W BY H E A LT H C A N A DA
FO R E X PA N S I O N O F I N DI C AT I O N S 88
A B OU T
E X P R E S S S CR IP T S C A N A D A ® 89
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EXECUTIVE
SUMMARY
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EXECUTIVE SUMMARY
This year’s Prescription Drug Trend Report maps a In 2018, also for the first time, we’ve added
continued deceleration in the longer-term trend of adherence patterns to our therapy class reporting. It
rapid increases in private plan spending. When we has become increasingly evident that nonadherence,
began reporting on the pharmaceutical landscape two the inability of patients to take their medications
decades ago, the era of blockbuster drugs was still in as prescribed, is a primary cause of poorer health
its infancy, about to present the first major challenges outcomes and higher spending. The result of this
to sustainable prescription drug coverage. In 1998, research is an even more nuanced understanding
prescription drug spending in Canada (not including of the importance of customized tools to meet the
hospital-administered drugs) was $8 billion*. In unique needs of plan members at different stages
2018, that prescription drug spending was expected of their life and health.
to reach $33.7 billion**, the culmination of a trend
that far outpaced broader inflation. DRUG TRENDS AT A GLANCE
• I mplemented in Ontario on January 1, OHIP+ was
In the past few years, however, benefit plan design
a major factor in 2018. As a result, claims dropped
that empowers plan members, along with patent
for those under age 25 by 63% compared to 2017,
expirations and policy leadership on drug prices,
and spending in this demographic fell by 52% with
have contributed to a welcome reprieve, with overall
a significant impact on overall drug spending.
increases in cost per claimant of 2.9%, 2.5% and
(Without OHIP+, the increase in overall spending
0.9% in 2016, 2017 and 2018, respectively.
trend in 2018 would have been closer to 2.8%.) In
EXECUTIVE At the same time, the end of the blockbuster drug 2019, we will see the reversal of this impact, as the
SUMMARY
era has shifted pharma innovation efforts, and province’s new government has redesigned OHIP+
the drug development pipeline is now focused on to remove coverage eligibility for those with access
million-dollar-per-treatment drugs and emerging to private drug plans, effective April 1.
gene therapies. Even as spending on traditional
•S
pecialty spending has surged from 15% of total
medicines has at least temporarily stabilized, these
spending in 2008 to 30% in 2016, to 33% in
high-cost, specialty drugs are driving specialty
2018.
spending higher in recent years, with a positive
trend of 6.9% in 2018. Almost triple Canada’s overall •P
atients with chronic conditions had especially
inflation in these periods, these increases make it high levels of nonadherence, including 70% of plan
clear that specialty medicines must be carefully members with asthma, 47% with cancer, 45% with
and proactively managed. The stratospheric prices diabetes and 45% with inflammatory conditions.
of these breakthrough treatments mean that benefit Treatment complexity is associated with poorer
plan design must be equally innovative to protect adherence: with one medication, 44% of patients
treatment access and plan sustainability. are nonadherent; with two to three, that number
rises to 58%; 77% of those using four or more
By applying our clinical expertise to the analysis of the medications are nonadherent to at least one of
“big data” inherent in processing claims for millions their treatments and 20% are nonadherent to the
of Canadians, Express Scripts Canada has identified majority of their medications.
the claim patterns that reveal where plan members
need support and where spending that doesn’t
contribute to better health can be avoided. For the
first time, we’ve also investigated the variations of
needs between members of different life stages.
Within the report, you’ll find examples of generational
challenges and targeted solutions through the lens
of a single but typical Canadian family.
*https://www.cihi.ca/en/drug_spend_drivers_en.pdf
**https://www.benefitscanada.com/news/prescription-drug-
spending-in-canada-to-hit-33-7b-in-2018-report-121979
EXPRESS SCRIPTS CANADA PRESCRIPTION DRUG TREND REPORT 5 @ExpressRxCanada
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EXECUTIVE SUMMARY
• Perhaps not surprisingly, in light of the figures above, •O
ur research aligns with many studies showing
the top 20% of plan members (ranked by spending) that patients with other chronic conditions are
account for almost 80% of total spending. These more likely to use a medication for mental health.
members struggle with the complexity of treating Overall, one in four claimants (24.7%) is using a
their chronic conditions, and their annual spending is, mental health therapy. However, almost 6 in 10
on average, $3,485, which is 15.6 times that of other multiple sclerosis (MS) patients (57%) and about
members. They have an average of 5.7 conditions one in three cancer, asthma and diabetes patients
(compared to 2.5 for typical members), an average of use at least one mental health medication.
3.7 prescribers and an average of 8.6 medications.
“
SUMMARY
With increasing drug costs and Canada’s aging FOR PLAN SPONSORS:
population, benefit plan sustainability depends
•R
eduction in spending to maintain the sustainability
on effective, individualized care that empowers
of the drug benefits that are so highly valued by
To ensure access
members to choose their best treatment options.
employees, while supporting productivity and
The Papadopolous family’s experience illustrates the engagement.
power of a personalized, holistic approach to care,
to treatment and
At Express Scripts Canada, our retrospective “big
which makes it possible to cost-effectively deliver
data” analysis goes beyond even the most recent
needed treatment. Even within a swiftly evolving
science to tell us what tools really make a difference
pharmacy landscape, the benefits are clear:
benefit sustainability
for members and their families. By starting with
FOR PLAN MEMBERS: clinical evidence, we can help family decision-makers
resist market forces – to choose the very best care
•T
argeted, proven tools to assist individuals for their family.
throughout their life span, from childhood to
retirement and beyond.
• Tailored solutions, when and where they’re needed.
To ensure access to treatment and benefit
sustainability in the years ahead, a 360-degree
in the years ahead, a
360-degree approach
approach to care is essential. With our plans, our
•A
ssistance for families, helping them to efficiently partners, policy makers and the supply chain, we
manage their prescription drug treatments, which can work together to ensure Canadians receive the
to care is essential.
make up the major portion of privately funded healthcare they need.
healthcare spending.
”
EXPRESS SCRIPTS CANADA PRESCRIPTION DRUG TREND REPORT 6 @ExpressRxCanada
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METHODOLOGY AND
TERMINOLOGY
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METHODOLOGY AND TERMINOLOGY
DRUG TREND REPORT METHODOLOGY
Express Script Canada’s drug trends measure the TERMINOLOGY USED IN THIS REPORT
rates of change in the gross cost per claimant,
which includes the eligible drug cost as well as
MEDICATION GROUPINGS:
the eligible dispensing fee. Gross cost includes the • Therapy class: A grouping of medications based
member’s portion of the eligible cost as well as the on their most common indication.
plan sponsor’s portion of the eligible cost. Claimant • Specialty drugs: Medications used to treat chronic,
includes each unique individual with a prescription, complex conditions such as severe rheumatoid
including all dependents who are eligible for coverage. arthritis, multiple sclerosis and cancer. Specialty
medications include injectable and non-injectable
Total trends comprise the utilization trend and cost
drugs and have one or more of the following
per prescription trend. Utilization trends are the
qualities: frequent dosing adjustments and intensive
rates of change in the number of eligible prescription
clinical monitoring; intensive patient training and
drug claims per claimant. Cost per prescription
compliance assistance; limited distribution; and/or
trends are the rates of change in eligible cost per
specialized handling or administration.
prescription. Only claimants who were continuously
eligible for coverage throughout the course of the • Traditional drugs: Medications that are easy to
year were included. Claimants who were not eligible self-administer and require less intensive clinical
METHODOLOGY AND for coverage throughout the entire calendar year were monitoring, such as those used to treat diabetes
excluded from the analysis. and high blood pressure.
TERMINOLOGY
Please note: Express Scripts Canada’s drug trend is OVERALL TERMINOLOGY:
based on a retrospective or historical methodology
•S
pending: Total cost of eligible prescription drugs,
– a look back at the past. In this way, it differs from
including the plan member’s portion as well as the
an insurance carrier’s health plan premium increase,
plan sponsor’s portion net of any Product Listing
which is based on a prospective methodology. An
Agreement discounts.
insurance carrier’s health plan premium increase
incorporates data trends to anticipate future costs •C
laimant, Member or Patient: Each unique person
• DRUG TREND REPORT METHODOLOGY including a drug plan’s specific claims experience, who submits a prescription drug claim, including
changes in proportion of eligible members with a all dependents who are eligible for coverage.
claim, demographic changes, anticipated changes •T
rend: The historical increase in cost per member
in the future mix of drugs, any erosion of member over the previous year, which includes the eligible
contributions, a risk component, and other health drug cost as well as the eligible dispensing fee.
plan claims experience. As a result, Express Scripts The total trend is made up of:
Canada’s trend factor will typically be lower than an
−T
he utilization trend: The rate of change in the
insurance carrier’s predicted average increase for
number of eligible prescription drug claims per
extended healthcare plans, of which prescription
member.
drugs are only one component.
−T
he cost/Rx trend: The rate of change in eligible
ADHERENCE cost per prescription drug claim.
Adherence was calculated using the medication
possession ratio (MPR), which is the sum of the days’
supply for all fills of oral medications in a particular
period, divided by the number of days in the period,
for any patient with three or more fills of the drug
during the period. Patients with an MPR of less than
0.8 or 80% were considered nonadherent.
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INSIGHTS INTO CHALLENGES AND
OPPORTUNITIES
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SECTION 1 – INSIGHTS INTO CHALLENGES AND OPPORTUNITIES
When we first began reporting on drug trends 20 years At the same time, we have now entered an age
ago, the prescription drug market was dramatically of million-dollar-per-treatment drug launches and
different than it is today. The era of blockbuster drugs emerging gene therapies. Innovations that deliver
– drugs formulated to treat millions of people with potentially breakthrough treatments with stratospheric
common conditions – was just taking off. That wave prices require us to be equally innovative in how we
of development represented one of the first major manage medications.
challenges to sustainable prescription drug coverage.
To ensure access to treatment and benefit
In 1998, prescription drug spending in Canada outside
sustainability in the years ahead, a 360-degree
hospitals was $8 billion*. In 2018, that number was
approach to care is essential. With our plans, our
expected to reach $33.7 billion**, the culmination of
partners, policy makers and the supply chain, we
a trend that far outpaced broader inflation.
can work together to ensure Canadians receive the
In the past few years, wider adoption of plan design healthcare they need.
that empowers plan members and policy leadership
*https://www.cihi.ca/en/drug_spend_drivers_en.pdf
on drug prices have contributed to a welcome reprieve
**https://www.benefitscanada.com/news/prescription-drug-
in the trajectory of the overall trend. spending-in-canada-to-hit-33-7b-in-2018-report-121979
DRUG SPEND PER CLAIMANT
INSIGHTS INTO CHALLENGES AND
NATIONAL DRUG TREND
INCREASE IN DRUG SPEND PER CLAIMANT SLOWED IN 2018 …
OPPORTUNITIES
+0.9%
+2.5%
ANNUAL DRUG SPEND PER CLAIMANT
+2.9%
$900
$800
$700
$600
TRADITIONAL
$500 SPECIALTY
• DRUG SPEND PER CLAIMANT $400
$300
• SUPPORT AND SOLUTIONS – THE PRINCIPLES OF $200
APPLYING DRUG BENEFIT SOLUTIONS $100
$0
• PATIENT INSIGHTS 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
• SUMMARY In 2018, we saw the rate of growth in drug spending over 2017, compared to 2.5% and 2.9% in the prior
per claimant slow down to an increase of 0.9% two years.
OHIP+ IMPACT ON TREND
OHIP +: CHILDREN AND YOUTH PHARMACARE
OHIP+: Children and Youth Pharmacare (OHIP+) at no cost, with no co-payment or annual deductible.
is an Ontario government provincial drug coverage Enrollment in OHIP+ is automatic based on age for
program that provides free prescription drug coverage all infants, children and youth with an Ontario health
for individuals 24 years of age and under. OHIP+ card number.
provides drug coverage under the Ontario Drug
OHIP+ coverage started on January 1, 2018. As of
Benefit (ODB) program regardless of family income
April 1, 2019, OHIP+ changed for those individuals
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SECTION 1 – INSIGHTS INTO CHALLENGES AND OPPORTUNITIES SECTION 1 – INSIGHTS INTO CHALLENGES AND OPPORTUNITIES
with access to private drug plan coverage. For those •F
ewer claims per claimant for those under 25. In CHALLENGES REVEALED
with a private plan, access to prescribed medications 2017, 9.1% of claims in Ontario were for members
returns to the state that existed prior to the launch of under age 25. This dropped to 4.3% in 2018. 1. COST/SUSTAINABILITY
OHIP+ on January 1, 2018; that is, they are no longer Growth in new high-cost therapies continues to be a Employers and plan sponsors will continue to face
The overall result was a 52% reduction in spend
eligible for OHIP+ coverage but instead are required primary spending driver. These drugs dominate the the challenges of supporting costly novel therapies.
by this demographic, with a significant impact on development pipeline, and the number of disorders
to submit prescription drug claims to their private
overall drug spend. for which they are approved continues to expand. As a
drug plan. Individuals and families with significant
out-of-pocket costs, despite having a private drug If OHIP+ had not been introduced, the increase in result, balancing patient care and plan sustainability
plan, can apply for additional financial support overall spending in 2018 would have been closer to is an ongoing, increasing challenge for plan sponsors.
through the Trillium Drug Program. 2.8%, in line with the previous two years.
OUTLOOK ON FUTURE DRUG SPEND
OHIP+ was implemented in Ontario on January 1, 2018. In 2019, we will see a reversal of this impact, as the
As a result, we saw a 63% drop in claims for those
GROWTH IN NEW HIGH-COST THERAPIES WILL CONTINUE
province’s new government has redesigned OHIP+
under age 25 versus the previous year with: TO DRIVE FUTURE BENEFIT COSTS
to remove coverage eligibility for those with access
to private drug plan coverage, effective on April 1.
•A
lower number of claimants. In 2017, 24% of
ANNUAL DRUG SPEND PER
all claimants in Ontario were under age 25. This
dropped to 18% in 2018.
PAYOR CHALLENGE
• Balance patient
CLAIMANT
SPECIALTY SPENDING CONTINUES TO GROW AT A DRAMATIC RATE care and benefit
YOU
ARE affordability
HERE
NATIONAL DRUG TREND • Help drive lower
costs and heathier
… HOWEVER SPECIALTY CONTINUES TO GROW AT A DRAMATIC RATE outcomes
ANNUAL DRUG SPEND PER CLAIMANT
$900 2015 2016 2017 2018 2019 2020 2021
$800
$700 To make funding available for these costly but The full benefit of medications can only be achieved
$600 lifesaving therapies without threatening plan if patients follow prescribed regimens. Yet a 2015
% OF TOTAL sustainability, plan members need effective, Canadian survey found that 30% of patients stopped
$500
TR ADITIONA L timely support. Within today’s highly complex taking a drug before they were advised to do so;
$400 67% pharmaceutical landscape, most plan members don’t 26% took less medication than they were instructed
$300 70% 69%
SPECIA LT Y
have the knowledge or time they need to make the to take; 26% did not fill a prescription they were
$200 88% 30% 31% best decisions. Instead, marketplace forces make given by their healthcare provider. Only 12% of
85% 33%
$100 22% it likely their choices will increase plan and out- those not filling a prescription and 8% of those not
15% of-pocket spending significantly, without improving taking their medication as prescribed stated that
$0
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 health outcomes. affordability was a factor in their nonadherence. This
means that there are other factors that are causing
This breakdown between specialty and traditional specialty drugs represent a much lower proportion 2. ADHERENCE TO THERAPY nonadherence.
drug spending shows specialty’s upsurge from 15% of private plan spending. In contrast, in the Atlantic Adherence to medication is generally defined as
of total spending in 2008 to 30% in 2016, to 33% provinces, where the provincial drug plan is the payor Nonadherence leads to spending waste. The aphorism
the extent to which patients take medications as
in 2018. With a high proportion of specialty drugs of last resort, specialty drugs make up a greater attributed to former U.S. Surgeon General C. Everett
prescribed by their healthcare providers. This term
in the development pipeline, this trend is expected portion of private spending. (In the United States, Koop continues to hold true: “Drugs don’t work in
is preferred to the older terminology of compliance,
to continue, which we will review in more detail later. where private plans are paying the full amount of patients who don’t take them,” and is equally true of
which suggests a more passive role for patients,
specialty drug spending, specialty drugs represent patients who don’t take drugs as directed. Treatments
following “doctor’s orders” rather than following a
The specialty versus traditional spending breakdown 45% of spending.) already purchased are less effective or ineffective;
treatment plan developed jointly by the patient and
varies by province. In the western “pharmacare” worsening conditions mean additional and often more
the physician.
provinces such as British Columbia, the provincial costly therapies may be needed.
plans provide a significant amount of coverage, so
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Medication adherence can be assessed in a number With access to immense claims data, we use a metric NONADHERENCE TO THERAPY
of different ways. The most common are: known as Medication Possession Ratio (MPR). With CLAIMANTS USING MULTIPLE MEDICATIONS ARE MORE LIKELY
this indirect, non-invasive approach, we cannot know
•M
onitoring patient behaviours (e.g., electronic TO BE DEEMED NONADHERENT
if patients take the medication they have on hand,
detection of a dose of a medication being but we know with 100% certainty they cannot take
administered); medication they do not have. Patients with an MPR < % OF NONADHERENT
% OF NONADHERENT
• Patient self-reports (e.g., surveys); 80% are considered to be nonadherent, as they have CLAIMANTS TO
CLAIMANTS TO AT LEAST
THE MAJORITY OF
• Pharmacy claims data. not purchased enough medication to be adherent. ONE MEDICATION
THEIR MEDICATIONS
POOR ADHERENCE ACROSS DRUG THERAPY CLASSES
CLAIMANTS USING 1 MEDICATION 44% 44%
NONADHERENCE BY THERAPY CLASS
POOR ADHERENCE OBSERVED ACROSS SEVERAL CLASSES
% OF NONADHERENT CLAIMANTS
CLAIMANTS USING 2-3 MEDICATIONS 58% 25%
Asthma / COPD 72%
Cancer 47%
Diabetes 45%
CLAIMANTS USING 4+ MEDICATIONS 77% 20%
Inflammatory Conditions 45%
Depression 37%
Multiple Sclerosis 32% •4
4% of claimants using one medication are Of greatest concern is the 20% of claimants who use
nonadherent; more than four medications and who are nonadherent
High Blood Pressure 29% to the majority of their medications, illustrating the
•5
8% of claimants using two to three medications
are nonadherent to at least one of their treatments; links between treatment complexity and gaps in
•O
ur research determined that over 70% of plan The causes of nonadherence are complex and and care. This has the potential to accelerate spending
members with asthma or COPD were not adherent. multidimensional, involving the patient, healthcare increases in this more vulnerable patient population.
•7
7% of claimants using four or more medications
•H
igh levels of nonadherence were also identified provider, drug and health system. are nonadherent to at least one of their treatments. 3. MANAGING TREATMENT COMPLEXITY
among members being treated for cancer (47%), Our claims analysis reveals that one patient factor The top 20% of plan members (ranked by spending)
diabetes (45%) and inflammatory conditions (45%). that increases nonadherence is the use of multiple account for almost 80% of total spending.
•3
7% of patients with depression, 32% with multiple medications.
sclerosis and 29% with high blood pressure were
not adherent with at least one of their medications.
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80/20 RULE MENTAL HEALTH
TOP 20% OF CLAIMANTS, WHICH ACCOUNT FOR 79% OF SPEND, PATIENTS WITH CHRONIC CONDITIONS ARE MORE LIKELY TO USE
FACE HIGHER LEVELS OF COST AND COMPLEXITY MENTAL HEALTH MEDICATIONS
% OF CLAIMANTS ALSO USING MENTAL HEALTH MEDICATIONS
TYPICAL CLAIMANT TOP 20% Multiple Sclerosis 57%
TYPE OF CLAIMANT
80% TOTAL CLAIMANTS 20% 43%
Blood Disorders
21% TOTAL SPEND 79%
Cancer 39%
ANNUAL COST $223 $3,485
AVG PER CLAIMANT
Asthma / COPD 37%
# OF CONDITIONS 2.5 5.7
Diabetes 33%
# OF PHYSICIANS 2.0 3.7
•A
lmost 6 in 10 multiple sclerosis patients (57%)
# OF UNIQUE MEDICATIONS 3.1 8.6
use at least one mental health medication;
% OF CLAIMANTS USING SPECIALTY 0.7% 12% •M
ore than 4 in 10 blood disorder patients use at
least one mental health medication; and
•M
ore than 1 in 3 cancer and asthma patients and
These members struggle with the complexity of Unsurprisingly, these challenges lead to greater
1 in 3 diabetes patients use at least one mental
treating their chronic conditions, and their annual levels of nonadherence.
health medication.
drug spending is 15.6 times that of other members,
an average of $3,485. These members are also more likely to use specialty
medications, and need help managing the treatment
THEIR CHALLENGES INCLUDE MANAGING: complexity inherent with this type of drug therapy.
However, our data analysis makes it clear that
•M
ultiple chronic conditions – an average of 5.7
members in the top 20% by spending struggle
medical conditions compared to 2.5 for typical
and need individualized support even if all their
members;
medications are in the traditional category.
•T
he coordination of care provided by multiple
physicians – an average of 3.7 prescribers 4. THE BODY-MIND CONNECTION
compared to 2 for typical members; Our research aligns with many other studies showing
•M
ultiple medications – an average of 8.6, almost that patients with other chronic conditions are more
three times more than typical members (with 3.1 likely to use a medication for mental health. These
medications). include medications for depression and other mood
disorders, anxiety, sleep disorders, and antipsychotic
medications. Overall, one in four claimants (24.7%)
are using a mental health therapy. This is higher in
Quebec (28.4%) than in the rest of Canada (23.5%).
However, claimants with chronic medical conditions
such as MS, cancer and diabetes have a notably
higher use of mental health medications.
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SUPPORT AND SOLUTIONS – THE PRINCIPLES •S
tep Therapy Program – An automated tool that
ensures that the most cost-effective therapies
A PERSONALIZED, HOLISTIC APPROACH
TO CARE
OF APPLYING DRUG BENEFIT SOLUTIONS are used first, before less cost-effective options.
Just like their fingerprints, the health and healthcare
TOOLS TO MANAGE SPEND 3. Channel Management – Uses a network of preferred needs of every individual are unique to them. Our
COMPREHENSIVELY MANAGED PLANS CAN BEND THE CURVE ON DRUG SPENDING pharmacies to drive down costs while delivering research reveals that, to be fully effective, plan
optimal patient care. These tools include: management tools must help patients on a personal
$$$ COMPREHENSIVELY MANAGED PLAN TOOLS: •A
Pharmacy Value Finder – Patient-accessible
level.
Formulary management web-based tool to assist members in finding To realize the full benefits of drug treatment plans,
Provide access to clinically effective medications the lowest-cost retail pharmacy in their area the focus of care must shift from treatment to the
ANNUAL DRUG SPEND PER CLAIMANT
while targeting high-cost therapies that offer no and plan network; whole patient. This also means closing gaps in care,
added clinical benefit.
especially among members who have more than one
•H
ome Delivery of Maintenance Drugs – Delivery
Utilization management chronic condition and multiple physicians.
of three-month supplies of regularly used drugs
Use of tools such as prior authorization (PA) and
for chronic medical conditions, with auto-refill Proactive pharmacy and claims processing design
step therapy programs to guide patients to safer,
more cost-effective drug choices and to ensure the capability, to help improve adherence while lessens the risk that members may take one or more
right drug is provided to the right patient, by the lowering costs; and medications inappropriately, helping to ensure safety
right payor, at the right time.
• Specialty Pharmacy – Providing a full range of and adherence across their treatment regimen, and
$ Channel management
Leveraging a network of preferred pharmacies to
patient-focused clinical and operational services
to enhance the safety, quality and affordability
reducing duplications.
drive down costs while delivering better patient A 360-degree view of patient health drives a
of care for patients using specialty drugs.
care. 180-degree change in health outcomes, by shifting
4.
P a tien t Healt h Managemen t – Providing from a reactive system to a proactive, holistic
Patient health management
Specialized holistic care can help patients better specialized, holistic care to help patients better approach to health and disease management.
manage treatment complexity to achieve lower costs manage treatment complexity, lowering costs
and healthier outcomes. and improving health outcomes. This includes
access to a Therapeutic Resource Centre, with
pharmacy specialists who provide patient-focused
Our data analysis and research make it clear that, 1. Formulary Management – Uses an actively managed
consultation to assist in the management of
to maintain benefit sustainability, manage their out- drug benefit formulary to provide enhanced access
chronic diseases and the medications prescribed
of-pocket spending and achieve optimum health to the most clinically effective medications,
for them.
outcomes, plan members need help. In the face of while targeting high-cost therapies that offer
time pressure and a complex healthcare system, no additional clinical benefit. This is further
this help must be clinically informed and delivered enhanced by a patient-accessible, web-based
at the right time. tool that assists members in understanding the
costs of their medications and the cost-effective
Comprehensively managed plans use a full menu of alternatives available.
managed plan tools to improve care and bend the
curve on drug spending. These tools can help address 2. Utilization Management – Using tools and programs
the challenges of cost, adherence, complexity and to ensure that the right drug is provided to the
gaps in treatment. Plan design starts with a clinical right patient, at the right time, and is paid for
approach – that is, first applying clinical guidelines by the right plan. Utilization management tools
and the latest health research – overlaid with a include:
proactive approach to managing market conditions.
•P
rior Authorization (PA) – Manages higher-cost
This two-pronged approach leverages the impact
drug claims to ensure that these therapies are
of benefit management tools, including formulary
used by the most clinically appropriate patients;
management, utilization management, channel
management and patient health management, as
follows:
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ESC_191000_RapportAnn_En.indd 22-23 19-04-30 16:02SECTION 1 – INSIGHTS INTO CHALLENGES AND OPPORTUNITIES SECTION 1 – INSIGHTS INTO CHALLENGES AND OPPORTUNITIES
PATIENT INSIGHTS MOM – HELEN
Helen is the primary caregiver for her family. She’s embarrassed about missing her medication
COMPREHENSIVE BENEFIT MANAGEMENT IN ACTION
Everyone counts on her to prepare family meals, and therefore doesn’t mention it to her doctor, only
THE PAPADOPOULOS FAMILY* including lunches for school and work. Like many saying that she’s tired.
parents whose spouses bring in the lion’s share of
Helen needs help to stay on track with her medication,
the family income and don’t have much flexibility in
feel better and have more energy to manage her busy
their day, Helen is in charge of making sure everyone
life. She is experiencing unintentional nonadherence.
in the family keeps their medical appointments and
takes any prescribed medication. With three boys
COMPREHENSIVE PLAN OPPORTUNITIES
(Jason, Alex and Chris), Helen is also the chief
activity officer, driving the kids to and from soccer Channel management, via the implementation of a
and hockey and making sure they’re registered, Home Delivery program, can help ensure that Helen’s
equipped and appropriately cheered. And if that isn’t prescription is refilled before she runs out.
enough to make you tired, Helen also works full time.
•R
eceiving a three-month supply of medication
directly to her home means she doesn’t have to
HELEN’S PRIMARY HEALTH CHALLENGES
find time to drive to a pharmacy to pick up her
Helen has hypothyroidism, which is treated with prescription each month.
levothyroxine. She’s been using it for over a year.
•A
n auto-refill service means she doesn’t have to
But like most primary caregivers, Helen tends to
rely on her memory to get her refills on time.
put herself and her health last on her priority list.
THE PAPADOPOULOS FAMILY She frequently misses doses – in fact, it happens •B
y moving from a one-to three-month supply,
Like many Canadian families, the Papadopoulos three or four times a week, meaning that her thyroid dispensing costs are reduced, and two items are
family is multigenerational. Helen and her husband condition is not well-controlled. taken off Helen’s epic to-do list.
John have three young boys, and Helen’s parents live
with them in a downstairs suite. She’s felt better since she started taking levothyroxine Ensuring that Helen has medication on hand when
but has been late to order her refills for each of the she needs it allows her to stay adherent. The result
WITHIN THE FAMILY, THE HEALTHCARE NEEDS last three months and has missed doses as a result. is a better health outcome – she feels better and has
ARE DIVERSE: Lately, she has been feeling fatigued, especially in more energy to manage her busy life.
the afternoons, but chalks it up to the additional
•H
elen is taking a medication for low thyroid
stress she’s coping with at work and with her dad.
function;
• J ohn has a painful inflammatory condition called
ankylosing spondylitis (AS); MEET HELEN …
• Alex, the middle child, has asthma; 38-YEAR-OLD MOTHER OF THREE BOYS.
• Helen’s father, Gus, lives with diabetes. • Primary family caregiver
• Managing activities of children
As each member of the Papadopoulos family has • Works full time outside of the home
unique health and healthcare needs, a personalized HAS LOW THYROID HORMONE LEVELS
and holistic approach is required.
CHALLENGE OPPORTUNITY DESIRED OUTCOME
Helen is struggling with adherence:
Formulary Management
• Remembering to pick up her thyroid medication LOWER COSTS
at the pharmacy each month. Utilization Management
+
Channel Management HEALTHIER
OUTCOMES
Patient Health Management
*The Papadopoulos family is a fictional representation of a typical
Canadian multigenerational family.
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ESC_191000_RapportAnn_En.indd 24-25 19-04-30 16:02SECTION 1 – INSIGHTS INTO CHALLENGES AND OPPORTUNITIES SECTION 1 – INSIGHTS INTO CHALLENGES AND OPPORTUNITIES
DAD – JOHN •T
rain John in self-administering his treatment by multiple conditions, numerous physicians, and the
subcutaneous injection; use of a new high-cost specialty drug. Many of the
John is his family’s primary income earner. He has particularly for individuals new to therapy. These
•P
rovide the counselling he needs, including side tools available through his comprehensively managed
been treated for depression and high blood pressure are recommended for use before approval of Enbrel.
effect management and encouragement; drug plan will prove to be extremely valuable.
for the past three years. His medications include:
Channel Management via a Specialty
•A
ssist with the challenges inherent in managing The Therapeutic Resource Centre pharmacists will
•F
or depression: sertraline 25 mg once a day – Pharmacy Program
multiple medications for multiple chronic diseases continue to provide John with assistance in managing
prescribed and monitored by his psychiatrist; A Preferred Provider Network with a Specialty from multiple prescribers, such as drug interactions; use of his new specialty medication, and he will be
•F
or high blood pressure: amlodipine 10 mg once a Pharmacy can help John and other patients like him: monitored for adherence.
•R
each out to prescribers when needed to optimize
day – prescribed and monitored by his cardiologist. •L
ower plan and out-of-pocket drug costs through John’s therapy.
a mark-up cap (fixed-dollar maximum versus
JOHN’S PRIMARY HEALTH CHALLENGES John is facing many challenges within his complex
percentage of dollar costs with no maximum);
John is a maintenance electrician, which involves health situation. He needs assistance managing his
•C
ontrol dispensing fees; and
hard physical labour, crawling in small spaces,
and many repetitive motions. When he started to •M
anage adherence by using home delivery and
experience low-back pain last year, he first assumed reminders to ensure that he has his medication on MEET JOHN …
he’d hurt something at work and tried to treat the hand when he needs it, without exception. 40-YEAR-OLD FATHER OF THREE BOYS.
pain with over-the-counter anti-inflammatories. • Primary income earner
John has access to Reimbursement Navigation
• Works as a maintenance electrician
Recently, John’s family doctor recommended that John Advocate Services through his use of the Specialty
IS BEING TREATED FOR DEPRESSION AND HIGH BLOOD PRESSURE
be evaluated by a rheumatologist, suspecting that he Pharmacy. The Advocate Services specialist
facilitated completion of the Prior Authorization form RECENTLY DIAGNOSED WITH ANKYLOSING SPONDYLITIS (AS) BY HIS RHEUMATOLOGIST
may actually have an inflammatory condition rather
than simple chronic back pain. The rheumatologist and assisted John in obtaining secondary coverage
CHALLENGES OPPORTUNITY DESIRED OUTCOME
diagnosed John with ankylosing spondylitis (AS) and assistance with his share of the high prescription cost.
• John needs help understanding the latest diagnosis
prescribed the specialty medication Enbrel, which Formulary Management
For families with tight budgets and full calendars like by his rheumatologist and the corresponding
LOWER COSTS
John self-injects. specialty medication treatment that was prescribed
John’s, this can be a game changer. The service helps (Enbrel).
Utilization Management
+
John needs help understanding his diagnosis and members find complementary and alternative forms of Channel Management HEALTHIER
• John needs help managing multiple chronic
the prescribed treatment. With multiple chronic funding and reimbursement, lightening the burden on conditions, multiple prescribers. OUTCOMES
their personal finances as well as their plan. This may Patient Health Management
conditions (depression, high blood pressure and
ankylosing spondylitis) and prescribers, John is at include integration with public programs, such as the
high risk of nonadherence, gaps in care, worsening Trillium Drug Program in Ontario, and coordination
health and unnecessary medication spending. of benefits with other private drug plans if available.
It also helps members complete prior authorization
COMPREHENSIVE PLAN OPPORTUNITIES forms to avoid the delays and frustration that can
Utilization Management via Prior Authorization result when vital information is left out.
•E
nbrel (etanercept), along with other biologic Patient Health Management via
disease modifying anti-rheumatic drugs (DMARDs), Specialized Pharmacists
is managed with Prior Authorization, which helps
John’s Specialty Pharmacy program also gives him
ensure the right patients get the right drugs at
access to Therapeutic Resource Centre pharmacists
the right time. As part of the prior authorization
and a Specialty Pharmacy Case Manager, who
process, a step therapy protocol ensures that John
provide clinical counselling to help John take his
has used another therapy before using etanercept.
medication as directed, manage side effects and help
•P
rior Authorization can also point John towards him manage his medical appointments (including lab
biosimilars for Enbrel (Brenzys and Erelzi), tests and follow-ups). Together, they can:
which provide equivalent effects at lower cost,
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SON – ALEX
MEET ALEX …
Helen and John’s son, Alex, is 11 years old and has Helen shares her concerns about the possible side
had chronic asthma since he was eight. effects of “long-term steroid use,” especially the 11-YEAR-OLD CHILD
potential for growth suppression, so the pharmacist ASTHMA
His treatment is: provides information on the benefits of Alex’s • Requiring maintenance medication
Maintenance with a regularly dosed daily low-dose control therapy versus the risks. This is an example • Experiencing daily symptoms
inhaled corticosteroid (ICS), Alvesco ® Metered-Dose of intentional nonadherence, which usually requires
Inhaler (MDI) 100 mcg (“controller” inhaler) one puff a form of behavioural intervention. Patient health
daily, plus salbutamol HFA MDI (a “rescue” inhaler) management delivered by the Therapeutic Resource CHALLENGE OPPORTUNITY DESIRED OUTCOME
100 mcg one to two puffs as needed. (The maximum Centre pharmacist fits the bill. By the time she hangs • Alex struggles with continuing asthma symptoms
Formulary Management
due to underuse of controller therapy and overuse
daily dose for someone Alex’s age should be four up, Helen understands that Alex’s asthma symptoms LOWER COSTS
of rescue therapy.
puffs per day; thus, one 200-dose MDI should last can be completely controlled if he uses his control
Utilization Management
+
50 days.) medication as directed – that is, he might never have Channel Management HEALTHIER
to use his rescue inhaler. OUTCOMES
ALEX’S PRIMARY HEALTH CHALLENGES Patient Health Management
Research tells us that there are many different
Alex is experiencing frequent asthma symptoms –
reasons for being nonadherent, some clinical, some
his asthma is not well-controlled. He is underusing
cost-related and some behavioural – so improving
his controller therapy (Alvesco), which he should be
adherence requires a highly personalized approach.
using every day, and overusing his rescue therapy
(salbutamol), which should be rarely required. While both Helen and Alex were nonadherent, Helen
wasn’t taking her medication as directed because
The family’s claims records show that Alex’s Alvesco
it was difficult for her to pick up (unintentional
has not been refilled in six months and that his
nonadherence). Alex wasn’t using his medication as
Salbutamol has been refilled monthly for the last
directed because his mom had unaddressed, natural
four months.
concerns about potential side effects (intentional
Alex is nonadherent and his health is suffering as nonadherence). These two different primary causes
a result. of nonadherence require different plan management
tools to resolve them.
COMPREHENSIVE PLAN OPPORTUNITIES
Through channel management and patient health
Channel Management via Preferred Provider Network
management, we can achieve lower costs and
Home Delivery Pharmacy
healthier outcomes including:
• Monitors Alex’s medication adherence;
• I mproved asthma control for Alex, with prescribed
•W
hen nonadherence is revealed, a pharmacist
use adherence for controller inhaler;
reaches out to Alex’s mom to let her know his
controller medication is not being refilled as • Decreased use of rescue inhaler;
needed and his rescue medication is being refilled • Preserved lung function over the long term;
too frequently.
• Increased ability for Alex to participate in daily
Patient Health Management activities (such as sports).
Since Alex’s mom is filling his inhalers through
the Home Delivery pharmacy, she has access to
the Therapeutic Resource Centre, which includes
a pharmacist trained in respiratory education. She
reaches out to Helen to discuss Alex’s condition as
well as the use of inhalers.
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GRANDDAD – GUS Gus’s pharmacist also notes a potential gap in care: Formular y management and patient health
according to guidelines, Gus should be taking a management help lower spending by starting
Gus is a 63-year-old retiree who, with his wife Georgia, •H
is high cholesterol drug therapy, Pravastatin, is
vascular protection drug such as an ACE inhibitor treatment with cost-effective alternatives. In addition
lives with their daughter Helen and her family. He also a Tier 2 drug. The total cost of one month
or ARB. to relieving the cost burden, these tools support
was recently diagnosed with type 2 diabetes. He of therapy at 80 mg per day is $27; Gus’s plan
better health outcomes, since better management
has private retiree drug coverage, but the annual pays $16, and Gus pays $11. Until now, it wasn’t As well, the pharmacist checks in with Gus to
of diabetes – treatment based on clinical guidelines
maximum is low, with coverage of $1,000 per year. a concern since it was Gus’s only drug spending. ensure he’s being screened for the complications
– can delay and reduce the risk of complications.
and conditions associated with diabetes, tracking
Gus’s doctor prescribed Onglyza (10 mg once daily) Patient Health Management via Disease
eye exams (to help prevent blindness), foot exams
to lower his blood glucose. Gus also takes Pravastatin Case Management
(to help prevent neuropathy and infection), testing
(80 mg, two 40 mg tablets, once daily) for his high Gus knows very little about managing his diabetes, for kidney function, and by conducting the PHQ-9
cholesterol and has been taking it for the past three and because he doesn’t want to be a bother to his questionnaire (obtaining baseline measurements and
years. doctor, doesn’t ask many questions. But Gus has updating periodically) for depression and anxiety.
access to a Disease Management program, including
GUS’S PRIMARY HEALTH CHALLENGES
a pharmacist trained in diabetes education who
Gus’s challenge is managing the costs of drug therapy provides advice and explains the alternatives for MEET GUS …
despite his plan’s $1,000 coverage cap. In addition, diabetes and high cholesterol treatment.
he is concerned about the effects of diabetes and 63-YEAR-OLD RETIREE
its long-term impact on his health. He is especially •D
iabetes – The pharmacist informs Gus that RECENTLY DIAGNOSED WITH TYPE 2 DIABETES
worried about the potential complications he has metformin, recommended by the Diabetes Canada • Has been using high cholesterol medication for three years
heard about, specifically blindness, amputation and Clinical Guidelines as the first-line drug for lowering • Has a retirement drug benefit plan with low annual maximum - $1,000/year
kidney failure. blood glucose, is on the top reimbursement tier of
his formulary (Tier 1). Together, they review the
Even with limited drug benefit coverage, there are cost using Gus’s plan’s Drug Look-Up feature and CHALLENGES OPPORTUNITY DESIRED OUTCOME
simple tools that can be used, beyond annual benefit • Gus struggles with the cost of his medications.
see that the total cost for one month (metformin Formulary Management
caps, to help manage drug benefit costs, while • Gus is worried about his diagnosis.
2,000 mg per day [4 x 500 mg]) is only $16, of LOWER COSTS
providing plan members access to cost-effective
therapies that drive positive health outcomes.
which Gus would only have to pay $2. Utilization Management
+
Channel Management HEALTHIER
•H
igh Cholesterol – The pharmacist advises Gus OUTCOMES
COMPREHENSIVE PLAN OPPORTUNITIES that a drug called rosuvastatin provides a more Patient Health Management
Formulary Management potent cholesterol-lowering effect, is on Tier 1 of
the formulary, and could allow Gus to achieve his
Gus’s managed formulary can direct him towards the
blood cholesterol target with a lower dose. Using
use of the most cost-effective therapies by providing
Drug Look-Up, Gus and the pharmacist see that
higher reimbursement for more cost-effective drugs.
one month of rosuvastatin 5 mg (an equivalent
Cost-effective therapy choices also lead to lower out-
to Gus’s current pravastatin dose) would cost a
of-pocket costs for plan members.
total of only $17; Gus’s out-of-pocket cost would
Gus calculates the costs of the new drug prescribed be just $2.
for diabetes in addition to his therapy for high
The pharmacist reassures Gus that he can effectively
cholesterol and sees that the plan portion alone will
manage his diabetes within the limits of his drug plan.
exceed his annual limit. Gus wants to know if there
By keeping his blood sugar levels under control, he
are alternatives that can bring his costs in line with
can reduce his risks of the long-term complications
his drug plan’s ceiling.
he is naturally concerned about. The pharmacist
•H
is newly prescribed diabetes drug therapy, refers Gus to the Diabetes Canada website and
Onglyza, is a Tier 2 drug. The total cost of one programs, drawing his attention to a patient-friendly
month of treatment is $111. Gus’s plan pays 60% explanation of the essentials of diabetes care, based
co-insurance for a Tier 2 drug, leaving Gus with on the Diabetes Canada Clinical Guidelines.
an out-of-pocket cost of $44.
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ESC_191000_RapportAnn_En.indd 30-31 19-04-30 16:02SECTION 1 – INSIGHTS INTO CHALLENGES AND OPPORTUNITIES
SUMMARY
With increasing drug costs and Canada’s aging FOR PLAN SPONSORS:
population, benefit plan sustainability depends
•R
eduction in spending to maintain the sustainability
“
on effective, individualized care that empowers
of the drug benefits that are so highly valued by
members to choose their best treatment options.
employees, while supporting productivity and
The Papadopolous family’s experience illustrates the engagement.
power of a personalized, holistic approach to care,
At Express Scripts Canada, our retrospective “big
which makes it possible to cost-effectively deliver
data” analysis goes beyond even the most recent
needed treatment. Even within a swiftly evolving
Comprehensively
science to tell us what tools really make a difference
pharmacy landscape, the benefits are clear:
for members and their families. By starting with
clinical evidence, we can help family decision-makers
managed plans use a
FOR PLAN MEMBERS:
resist market forces – to choose the very best care
•T
argeted, proven tools to assist individuals for their family.
full menu of managed
throughout their life span, from childhood to
retirement and beyond.
• Tailored solutions, when and where they’re needed.
•A
ssistance for families, helping them to efficiently
plan tools to improve
manage their prescription drug treatments, which
make up the major portion of privately funded
care and bend
healthcare spending.
the curve on drug
spending. These tools
can help address
the challenges of
cost, adherence,
complexity and gaps
in treatment.
EXPRESS SCRIPTS CANADA PRESCRIPTION DRUG TREND REPORT 32 @ExpressRxCanada
”
ESC_191000_RapportAnn_En.indd 32-33 19-04-30 16:02A LOOK AT THE OVERALL DRUG TREND
FOR 2018
ESC_191000_RapportAnn_En.indd 34-35 19-04-30 16:02SECTION 2 – A LOOK AT THE OVERALL DRUG TREND FOR 2018
OVERALL TREND IN 2018
For plan sponsors, protecting plan sustainability Nationally, the average annual drug spending per
starts with an understanding of the high-level member increased by 0.9%, to $869.56, less than
influences that affect benefit spending and the the spending increase of 2.5% in 2017.
health of members. In 2018, as for each year since
The 2018 overall trend was made up of a 1.8%
the launch of our first annual Drug Trend Report,
decrease in spending on traditional medications
Express Scripts Canada leveraged the vast amount
and an increase of 6.9% in spending on specialty
of data involved in processing the claims of millions
medications.
of Canadians to analyze these trends.
Private plan spending temporarily slowed in 2018,
in part due to the implementation of OHIP+.
TRADITIONAL VS. SPECIALTY
INCREASE IN SPECIALTY MASKED BY DECREASE IN TRADITIONAL
+0.9%
ANNUAL DRUG SPEND PER CLAIMANT
$900 2018 2018 VS. 2017
A LOOK AT THE OVERALL DRUG TREND $800
$700
FOR 2018
TRADITIONAL TRADITIONAL TREND
$600 98% OF CLAIMS - 1.8%
67% OF SPEND
$500
$400
$300
$200 SPECIALTY SPECIALTY TREND
$100 2% OF CLAIMS
33% OF SPEND
+ 6.9%
• OVERALL TREND IN 2018 $0
2017 2018
• TRADITIONAL DRUG TREND OVERVIEW Of note: Traditional drugs made up 98% of drug claims in 2018 but only 67% of drug spending, while specialty
drugs represented only 2% of 2018 drug claims but 33% of drug spending.
• SPECIALTY DRUG TREND OVERVIEW
• TOP TEN MEDICATIONS BY SPENDING
• TOP 10 THERAPY CLASSES – INSIGHTS FOR 2018
• OTHER NOTABLE THERAPY CLASSES
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ESC_191000_RapportAnn_En.indd 36-37 19-04-30 16:02SECTION 2 – A LOOK AT THE OVERALL DRUG TREND FOR 2018 SECTION 2 – A LOOK AT THE OVERALL DRUG TREND FOR 2018
TRADITIONAL DRUG TREND OVERVIEW SPECIALTY DRUG TREND OVERVIEW
TRADITIONAL DRUG TREND SPECIALTY DRUG TREND
DECLINE IN TRADITIONAL DRIVEN BY REDUCTION IN UTILIZATION GROWTH IN SPECIALTY DRIVEN BY GREATER UTILIZATION
= + = +
TRADITIONAL UTILIZATION COST/RX SPECIALTY UTILIZATION COST/RX
TREND TREND
-1.8% -1.4% -0.4% +6.9% +6.1% +0.8%
FACTORS DRIVING TRADITIONAL TREND IN 2018 18.6%
+2.8% FACTORS DRIVING SPECIALTY TREND IN 2018
+ Introduction of new, higher-cost brands
TRADITIONAL TREND
SPECIALTY TREND
12.1% + New high cost specialty medications
+ Shift to higher-cost medications
+0.8% + New indication approvals
-0.3% 6.5% +6.9%
– Impact of OHIP+ in Ontario
-1.3% – Ongoing patent expirations 2.9%
-1.8% – Impact of OHIP+ in Ontario
– pCPA negotiated generic prices – Higher adoption of plan controls and PLAs
– Greater use of plan design controls
2014
2015
2016
2017
2018
– Ongoing specialty patent expirations
2014
2015
2016
2017
2018
Traditional drugs are those used to treat common effective on April 1, 2018. Prices for almost 70 of Specialty spending continues to be a concern for 2. T
he introduction of new high-cost medications.
medical conditions such as diabetes, high blood the most commonly prescribed generic drugs were private plan sponsors. Over the course of the last Most drug development efforts are focused on
pressure and depression. In 2018, 98% of the total reduced by 25% to 40%, representing discounts decade, spending in this category has more than filling the remaining treatment gaps, which require
number of benefit claims made were for drugs in this of up to 90% off the price of their brand-name doubled. In 2018, specialty drugs represented 33% specialty medications.
category. From a spending perspective, traditional equivalents. of overall spending – despite representing just 2% 3. N
ew indication approvals for existing drugs, which
drugs accounted for 67% of the 2018 total, down of total claims. expand the number of patients who may use these
On the other hand, factors putting continued upward
from 69% in 2017. A total increase of 6.9% in 2018 followed an increase drugs.
pressure on spending in this category included new
The last two years brought a welcome respite in higher-cost brands, as well as a shift toward higher- of 6.5% in 2017. (Utilization increased by 6.1% and The specialty spending trend was softened slightly by
the longer-term upward trajectory of spending in the cost medications within therapy classes such as cost per prescription increased by 0.8% in 2018.) OHIP+ coverage and by a few patent expirations that
traditional category. Following a flat trend in 2017, diabetes. helped reduce the increase in cost per prescription,
The factors driving this steep increase included: as mentioned above in the traditional category
traditional spending declined by 1.8% in 2018 due
These factors, combined with the growing prevalence 1. H
igher utilization of specialty medications for analysis.
to decreases in both utilization (1.4%) and cost per
of these common conditions, have the potential to conditions such as:
prescription (0.4%).
have a massive impact on private plan costs going
Contributing factors include OHIP+ changes that forward. However, greater use of plan design controls a. A
sthma, which until recently was treated only
made more than 4,400 drugs free in Ontario for such as generic substitution and managed formularies with traditional drugs; and
those 24 years old or younger. Another major factor can help plans take advantage of the positive changes b. C
ancer, which was previously treated with
was generic price reductions by the pan-Canadian underway while managing the inflationary factors, to hospital-administered injectable drugs covered
Pharmaceutical Alliance (pCPA) that became achieve overall sustainability. by public health plans. The advent of specialty
oral cancer drugs has driven much of this cost
onto the private sector.
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