Insurers, plan sponsors may soon consider adding drug to formularies: Experts
Jonathan Zaid was 14 when doctors made the diagnosis: His unrelenting headaches — and debilitating pain — were caused by a condition called “new daily persistent headache.”
“I tried 48 prescription drugs and all kinds of other therapies, and none of those were indicated for my condition. The plan formulary covered every single one of those drugs without a question, but none of them were indicated or studied or researched for what I have,” said Zaid.
Eventually, he found something that worked: Medical marijuana.
Zaid is the first — and, so far, only — patient to receive insurance coverage from Sun Life Financial for medical cannabis through the University of Waterloo Student Union in Ontario.
It took a lot of education, advocacy and stigma reduction, he said — but it worked out for him in the end.
“They finally understood that it was necessary to cover it, and saw the impact that it would have on my life and my academics. And when they looked at the cost of it, they didn’t see that it would be a huge cost… it’s not that expensive in the context of pharmaceuticals.”
As things stand, insurance coverage for medical marijuana is a rarity in Canada — Zaid’s own case with Sun Life and Medavie Blue Cross are the only two plans that are publicly known to be paying for medical cannabis, he said.
Medical marijuana is considered to be a controlled substance and, as a result, it cannot be covered under regular supplementary health benefit plans, said Wendy Hope, vice-president of external relations at the Canadian Life and Health Insurance Association in Ottawa.
In rare circumstances, it may be covered on an exception basis at the request of a plan sponsor, as long as the plan can accommodate it.
But that might be about to change, according to Khurram Malik, co-head of research for investment bank Jacob Securities in Toronto.
“I think in (the near future) you’ll see some of the smaller insurance companies or the more niche-y ones covering it, and then you’ll see the larger ones,” he said.
Obstacles to acceptance
To qualify for insurance coverage, medical marijuana would need a drug identification number (DIN), said Hope, which it currently does not have.
“Like any new drug, medical marijuana would have to go through Health Canada’s assessment process before it could enter the marketplace as a prescription drug with a drug identification number (DIN). Only then can insurers consider providing coverage under its regular plans.”
Stigma and misconceptions around medical marijuana are another hurdle, said Cam Battley, vice-president of communications and corporate development at Bedrocan in Toronto, a producer of medical cannabis. That’s why many in the industry use the term “medical cannabis.”
“We call it medical cannabis and that’s a very important distinction because… what we do is very, very distinct from the perceptions… and the stigmas associated with street marijuana,” he said.
There certainly are still overtones of prohibition and illegitimacy, said Bruce Linton, chairman and co-founder of Tweed Marijuana in Smith Falls, Ont.
“(But) those go away more and more every day as we see indications of benefits across multiple user groups,” he said.
The biggest obstacle Zaid sees, whether for insurers, HR or regulators, is education.
“People have so many pre-conceived notions on marijuana and weed, and they don’t really understand medical cannabis. They don’t understand the use and they don’t understand the nuances,” he said.
“People aren’t going to work and (getting) high— they want to take the medicine to improve their quality of life… and they understand they can’t work properly when they’re intoxicated.”
Employers need to understand that medical cannabis patients are not using this product recreationally, said Battley.
“According to Health Canada statistics, the average patient is using approximately one gram of medical cannabis per day… that’s not sufficient for patients to get high, that is sufficient for patients to manage their chronic pain or manage the symptoms of an anxiety disorder,” he said. “So people are using this product responsibly.”
It may also ease the sense of legitimacy when medical cannabis is offered in a pill form, said Malik.
“That makes it considerably more appealing to doctors and considerably more appealing to the casual patient who maybe is not comfortable with marijuana in the traditional ways that you consume marijuana. It’s popping a pill rather than smoking it — it’s more convenient and it (reduces) the psychological stigma.”
Floodgates firmly closed
However, there are other dimensions to consider, including the public relations side of the coin, said Zaid.
“When the university considered (my) case, which took eight months and lots of deliberation and consideration, they looked at three main things. They looked at the economics… they looked at the impact on my academics,” he said.
“(And) they looked at the PR-side of things — what would it mean if they covered medical cannabis under an insurance plan? Would it open the floodgates and tons of students would try to access medical cannabis for recreational or non-medical purposes?”
For Zaid, the answer is no.
“People understand that medical cannabis is a medical treatment now, and part of that is that regulations are made so that it is difficult to access. Even people with an established medical need have difficulty accessing medical cannabis. So if you have no medical need and you have no documentation, it’s very challenging (to access),” he said.
“So we’re not seeing the floodgates open.”
Nobody is recommending medical cannabis as first-line therapy, said Battley.
“The patients that we have (at Bedrocan) typically have tried other therapies so they have been refractory to standard prescription regimens — or they have experienced such side effects that they were intolerable to the patient. So people do not tend to go for medical cannabis first; they tend to go for medical cannabis when other regimens have failed.”
Cost, risk benefits to medical cannabis
Some of the strongest arguments for insurance coverage of medical cannabis compare the costs and risks of cannabis versus other medical treatments, said Battley.
“There are some examples, like Jonathan’s, where there are clear economic offsets. The cost of medical cannabis is actually less than the cost of the previous regimen that medical cannabis is replacing,” he said.
In this way, it’s a profit motive for insurers and plan sponsors, said Malik.
“It’s cheaper for them to insure marijuana than it is to insure your typical, traditional medicines for certain maladies,” he said.
“It’s cheaper to insure than it is to insure opioids such as OxyContin.”
There are also factors of efficacy and liability, said Linton.
“The compelling reason for an insurer is… something that has less liability, equal or better efficacy and a lower cost base probably is a winner,” he said.
“So, on that basis, I do believe it will happen.
“If you have a choice of taking something that requires you to have a frequent liver function test or results in you having the inability to reliably turn up at work… or having something that doesn’t have those negative side-effects, the patient (will) demand that.”
Advocates for medical cannabis often compare it to other categories of medicine, said Battley.
“One very good example is opioids. Canada has a real opioid problem — we have the second-highest per-capita use of opioids in the world. And opioids come with a lot of problems,” he said.
“The first is the side-effects. Patients using opioids have real difficulties with nausea, with constipation, with mental confusion, and there’s that ever-present risk of addiction. Medical cannabis, when used by patients to manage a chronic pain condition, is typically used as an alternative to opioids.”
Competitiveness factor?
If plan sponsors start pushing to offer medical cannabis coverage, it probably won’t be long before others follow suit in a bid to stay competitive, said Malik.
“It’s a very cut-throat, competitive industry… it just takes one or two to be aggressively out there,” he said.
And if plan sponsors want it, insurers will do what they can to acquiesce, said Zaid.
“From my experience, the insurer probably matters the least out of any of the parties at hand. It really comes down to the employer and their willingness and incentive to put it onto the formulary. When we’re talking about large-scale employers — 100-plus employees — that big of a client is too important to an insurer to lose over a claim on medical cannabis.”
Coverage will likely remain an exception in the beginning, said Battley.
“However, I think as this evolves, it will be added as a standard benefit because there are wins in this for appropriate patients,” he said.
And the bottom-line benefit for employers? The ability to have productive, talented workers who may otherwise be suffering from debilitating symptoms, said Linton.
“We have a number of people who are legitimate patients who, without this medicine, may or may not be employed. And with it are fantastic, productive, creative people in our organization — and many of them are core leaders.”
