By Helen Stevenson, Guest Contributor

Of all the new drugs reviewed by the Reformulary Group’s Expert Committee in 2020, 23% have been for cancer drugs covered outside of provincial cancer agencies. What’s more, the Drug Early Warning (DEW) System that monitors new pipeline drugs found that 19% of all pipeline drugs are for treating cancer.

Understanding value in specialty drugs like these is not as straightforward as it can be for other categories of drugs. Cancer is a challenge, partly because of the fear it strikes in people’s hearts, the unknown pace of the cancer’s progression, the different types of cancer, and the fact that the regulators are approving some drugs much earlier, based on less data.

Plan administrators are left wondering which new specialty drugs must be – or should be – covered. But this is a complicated question. The decision requires a wide variety of inputs, ranging from safety and tolerability to efficacy and cost.

Decisions, Decisions: A Roadmap for Plan Sponsors

Plan sponsors struggling with these decisions need to develop a strong process to adjudicate requests for specialty drugs. This is critical to sustainable drug plan management. A robust special authorization process that leans on independent clinical expertise and carefully weighs the factors outlined in this article is another important element.

When it comes to managing the cost of cancer drugs, there are several factors to take into account. Consider the following:

  • Coordinate with provincial drug programs. Provincial funding for cancer drugs varies by province. Some provinces have different funding mechanisms depending on the administration of the drug; in Ontario, for example, IV cancer drugs are typically covered through the provincial cancer agency and administered in cancer centres, whereas oral cancer drugs may be funded through the Exceptional Access Program (EAP) of Ontario Public Drug Programs. Some Ontarians are also eligible for funding of EAP drugs through the Trillium Drug Program. Work with your insurance provider to discuss claims coordination for cancer drugs.
  • Stay informed. The landscape around cancer drugs is constantly shifting. While many older drugs have seen excellent results, newer ones (which tend to be more expensive) are being approved with uncertainty about their effectiveness. Work with your broker who may have the resources to navigate this space and guide plan sponsors in making smart decisions about coverage of these newer drugs.
  • Recognize complexity. Value around expensive cancer drugs is harder to discern than other drugs. Treatments often involve a focus on time left to live that’s absent from other medical conditions, which needs to be balanced against cost, safety, toxicity, side effects and many other factors.

There are rarely easy answers when it comes to how private drug plans handle claims for expensive cancer drugs. But making sure you know where your organization stands, and what the criterion for specialty drug coverage is can help.

Helen Stevenson is the Founder and CEO of Reformulary Group.

HUB International’s team of brokers is constantly in touch with new trends and developments in employee benefits, ensuring that clients can access the information needed to make informed decisions.