For years, experts have issued warnings about the need to control the spiralling cost of prescription drugs. Since the late 1980s, prescription drug costs in Canada have skyrocketed, and spending has increased 600%, according to the 2010 Group Health Care Cost Control in Canada report by the International Foundation of Employee Benefit Plans. This trend is simply not sustainable, and many provinces have introduced drug reforms intended to address this cost crisis, primarily for publicly funded drug benefits plans.

Benefits plan sponsors have been hit even harder. As only some of the drug reforms apply to the private sector, plan sponsors may be more vulnerable to cost increases, and they lack the leverage and tools to manage costs. And while generic pricing reforms have provided some short-term relief, the wave of specialty medications in the pipeline will cause drug costs to soar once again.

However, the sad fact is that while drug benefits coverage is becoming unaffordable for many plan sponsors, there is also a huge amount of money being wasted within some plans. For example, most plan sponsors have generic fill rates in the low 50% range; this indicates that patients are often taking a brand name drug when a lower-cost, clinically effective generic is available. This is only one of several points of waste within drug plans and evidence that plan sponsors have been unable to influence two key drivers of waste: the behaviour of plan members and the workings of the prescription drug supply chain.

Pharmacy benefit management (PBM) services are one option available to enable plan sponsors to better manage the cost of their prescription drug benefits while also providing members with an enhanced prescription drug service. While PBM services are more fully developed in the U.S., they are making their way into Canada.

For example, Express Scripts Canada’s PBM service uses tools that apply behavioural sciences to healthcare decision-making in order to influence plan member behaviour. Plan members, with the support of their physician, are encouraged to interact with a team of professionals to learn about their maintenance medication alternatives, thus enabling them to make more informed choices. The result will be decisions that offer the best possible health outcome while also reducing costs for both the plan member and the plan sponsor. Plan sponsors can add this service as an enhancement to an existing drug benefits plan without changing insurance carriers or adjudicators.

Therapy optimization is another important component of enhanced PBM services. Doctors often prescribe the higher-cost brand medication, which can be costly to both the patient and the plan sponsor. PBM services can help by developing and administering a therapy optimization program whereby a licensed pharmacist works with the patient and doctor to help them to consider replacing existing medications with clinically and/or therapeutically equivalent lower-cost alternatives. This program is particularly effective when used in conjunction with behavioural science tools.

A 2012 study that appeared in the Jan. 16, 2012, issue of the Canadian Medical Association Journal states that one in 10 Canadians don’t adhere to their prescription medication(s) due to cost concerns. An enhanced PBM service can provide tools and services to improve adherence as well as the affordability of medications. Patients are provided with access to tools that allow them to manage their prescription medications and are offered various services, including refill reminders and automatic refills, that help to ensure they have medication on hand when they need it.

With the coming wave of high-cost specialty drugs, a PBM service is one solution to enable plan members to make informed, cost-conscious decisions, while helping plan sponsors to preserve their drug benefits.

Michael Biskey is the president of Express Scripts Canada.

Copyright © 2022 Transcontinental Media G.P. Originally published on

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Scott Warner:

Really – This is an article ? This is an Advertisement for a US based PBM … clearly they have very little knowledge of Canada based on the “content” of the article … these are the same people who are trying the mail order thing right ?

Friday, April 27 at 8:13 am |

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