It is supposed to be the most exciting time of your life. The birth of your first child! You bring your beautiful new baby home and can’t wait to show her off to the world. After just a few short weeks at home you begin to notice you baby is not hitting any of her physical milestones. Concerned, you take her to the doctor and your life changes forever. Your baby has been diagnosed with Spinal Muscular Atrophy (SMA) which is a genetic disease affecting the central nervous system. Your baby has limited muscular control and it is expected to get progressively worse.
Enter Zolgensma – A biologic drug (produced from living organisms) approved in Canada that is injected once, and essentially repairs the damaged gene causing SMA. If the drug is started early enough the results are extremely positive.
So what is the catch? A price tag of between $2.1 – $2.8 million dollars. The drug was only recently approved in Canada and there are no other alternative or similar drugs. This drug will also likely remain in patent for years meaning lower cost (but equally effective) drugs will not be available for some time. This is the recent story of two BC families.
Each year many Canadian families are faced with a tough question. What to do when important drugs demand a ridiculous price tag for the most important of people? What if it was your child, your friend’s child or your own parent or spouse…maybe even or your own life?
So, we live in Canada and we have free healthcare don’t we? Unfortunately, prescription drug coverage under government health programs drastically varies based on one’s province of residence. Even those provinces with some drug coverage – not all drugs are covered (and even more rarely are the expensive drugs covered) and typically they are designed to benefit the low income earners.
What are the options for these families?
Extended Medical Plan from your Employer and Spouse’s Employer: many employers offer an extended health plan that will cover some of the cost of the drug. For expensive drugs, prior approval is required and you will be informed how much is to be covered. However, there are limitations to employer plans. They often have maximums ranging from $5,000-$50,000 per annum per person. In addition, where an Employer’s plan covers a significant portion, the employer will likely be facing a significant increase in rates. This is not a sustainable solution.
Provincial Pharmacare: in some cases provincial drug programs will cover a portion of the cost. Private drug plans typically cover anywhere from 10,000-15,000 different drugs, and provincial plans typically only cover about 2,500.
Couponing: a drug coupon is intended to help consumers save money on pharmaceutical drugs. They are offered by drug companies or distributed to consumers via doctors and pharmacists, and most can be obtained online.
Manufacturer Discounts: in some cases, drug manufacturers will work with families to provide a reduced price based on income, or offer a payment plan to help finance the expensive drug, simply because you asked and pleaded your case.
Go Fund Me: when all else fails, using a crowd funding platform such as Go Fund Me community support can be rallied to raise the funds needed. In the case of both families mentioned above, they turned to Go Fund Me and were able to raise enough to cover the cost of the drugs and help some other families in the same situation.
Our focus is to help Employers put in place effective, sustainable benefit plans. It is important the plan be well designed, but reasonable to ensure cost sustainability.
What does the future hold?
Prescription drugs typically take years to develop, test and go to market. A significant number of new drugs in the pipeline are biologic drugs and will come along with a hefty price tag. As more of these drugs enter the market employers can expect to see them hitting their prescription benefits plan.
There is some interesting news – a national drug program for all Canadians has entered the political radar. While this sort of program would likely take years to develop, we do expect it to become a stronger political issue that will need to be addressed.
There are also bio-similars. Just as we have generic drugs to substitute for brand name drugs at a reduced cost, bio-similars will allow other manufacturers to enter the market and when there is competition there are reduced prices. As patents expire for new biologic drugs we can expect to see more and more bio-similars.
It is important to ensure your benefits plan is set up in a sustainable way for your organization, ideally before an employee needs one of these drugs.
Call us and we will help you design the most affordable and flexible plan for you and your employees.
Your health is at stake!
Written by: Greg Shorter
A summary commentary based on the following sources: