Beneplan - Benefits Law & Admin Workshop - December 1 2015 - Mississauga, Ontario, Canada

The Beneplan Co-operative
1
Benefits Plan Administrator’s Workshop
!
December 1, 2015
2015

Beneplan Points of Contact
Vince Principato, Partner
Patricia Thomas, Benefits Consultant
Evelyne Mitskopoulos CNP, Director of Wellness
Johnathan Eagleson, Benefits Associate
Yafa Sakkejha, GM

• 9:30am - Overview of Renewal Calculations
• 10:00am - Plan Administration Guidelines
• 10:30am - Dr. Prouse PhD: Study on Personalized Medicine
• 10:45am - Evelyne Mitskopoulos CNP: Wellness in the
Workplace
• 11:30am - Martin Walker, LLQP, CEBS, The Co-operators
• 12:00pm - Lunch
• 1:00pm - Davies Howe Partners LLP on Benefits Law
Liability
• 2:30pm - Helen Stevenson, CEO, The Reformulary Group
• 3:30pm - Prize Draw and Adjourn
Agenda

Remember:
Insurers Brokers are paid a
% of the float
!
The leftover profit goes to the
members

The system is not
incentivized to reject the
maximum # of claims…

The system is incentivized
to approve the maximum
# of claims.

• In FY 2014, 70% of member-owners
received dividends
• 30% of members had deficits absorbed
by the co-operative — i.e. by you!
• Our role is to minimize deficits as much
as possible.
Patronage Dividends

Your Board sets policies designed to protect the
pool: your profits.
Board at the 2013 AGM

Renewals
How are your rates calculated?

• Calculated at Beneplan for health dental
• Based on the following:
• Weighted average of last 3 years’ usage
• Inflation: 6% Dental; 11% Health
• No IBNR built-in (taken from dividend)
• +Expense factor for fees, commissions,
and taxes (differs by company size)
Rate Setting: Health Dental

• TLR is a representation of the target profit
that the benefits company would retain.
Target Loss Ratio
0
25
50
75
100
TLR
$75 towards claims
$25 towards fees,
commissions, taxes
$100 in
premiums

• In your company, compare it to
mark-up vs margin on COGS
Target Loss Ratio
0
25
50
75
100
TLR
$75 is the Cost of Goods Sold
$25 is the margin
$100
cost of
shoe
…so what’s the mark-up on COGS?
=75/25, or 33%

• Which is better for the client? A
TLR of 75% or a TLR of 60%?
Target Loss Ratio
0
25
50
75
100
TLR
0
25
50
75
100
TLR
0
25
50
75
100
TLR

• Which proposal would you take?
Target Loss Ratio
Blue Trust
Insurance
True North
Insurance
Monthly
Premium
$3,000 $3,000
Target Loss Ratio 85% 75%

• Now which one would you take?
Target Loss Ratio
Blue Trust
Insurance
True North
Insurance
Monthly
Premium
$3,000 $2,000
Target Loss Ratio 85% 75%

Year
HD
Premium
HD
Claims
#
Months
Fam
Rate $
Usage
$
Weight-
ing
Pop.
2015 100,000 60,000 12 150 90 70% 55.5
2014 90,000 70,000 12 145 112 20% 51.7
2013 85,000 50,000 12 142 83 10% 49.8
Dental inflation 6%
Health inflation 11%
Fees Taxes 12%
Broker commission 5%
These elements help determine the rate

• Change in health of employees
• Rapid population change
• Turnover
• Average age
• Anti-selection
What affects your consumption?

• Low-Risk and High-Risk Tiers
• High-risk (unlimited drug plan)
• 7% to 15% depending upon the carrier.
• Low-risk (drug cap of $10,000 or less)
• $1 to $2 per Single; $2 to $4 per Family.
• Not EP3 Eligible
• Stop-loss pool is experience-rated - so you pay less if the
pool does well.
Rate Setting: Pooling Charges

• Life, ADD, LTD, CI
• Done at the insurance carrier
• Based on demographics
Rate Setting: Pooled Benefits

Beneplan.ca All rights reserved Beneplan Inc 2014
Day-to-Day Administration
27

Please let us know when….
28
• New employee
• Salary change
• New dependent
• Change of address / beneficiary
• Change to coverage (Single / Family)
• Someone is not actively at work (sick / other leaves)

Late Applicants
29

Who is Eligible to Join
Your Benefit Plan?
30

Eligibility to Join the Plan
31
• Active employees
• Employed by the employer
• Working on a regular permanent basis
• Working full-time for a minimum # of hours
• Not seasonal
• Member of an eligible class of employees
• Insured under a provincial government health insurance plan

Eligibility to Join the Plan
32
• Dependents
• Your legal spouse
• Common-law spouse after 12 months of cohabitation
• Your natural children
• The natural children of your spouse
• Children who are in your guardianship (need legal
docs)

Who is not eligible to join?
33
• Inactive employees
• Retired / independent contractors
• Someone employed by a different employer (no common ownership)
• Cannot be your cousin who just came to Canada and is not an employee
• Not working on a regular permanent basis
• Temp workers / part-timers
• Not full-time for a minimum # of hours
• An employee who is not covered under a Canadian provincial health plan.
• Parents / Grandparents / Grandchildren

Independent Contractors
34
• Never add an independent contractor onto
your benefit plan
• The CRA will deem them to be an
employee, and therefore, make you and
the individual pay back-owed taxes and
penalties

“What if I have many short-term contract
employees who I want to cover?”
35
• Let us know the nature of their work, and if
this is an essential part of your workflow
• If you want to offer them benefits, you
must:
• Enrol all employees in this class, not
only those who ‘choose to join’

Participation
36

Quiz:
Should you give employees the
choice to join the benefit plan?
37
Or should it be mandatory
of employment?

It should be mandatory of
employment.
!
In fact, if the insurer finds
out that a minimum # of
participation is not
achieved, they may not
agree to underwrite the risk.

How is ‘participation’
defined?
!
Enrolled in all pooled benefits
Life, ADD, WI, LTD, CI
Enrolled in health dental; or,
Opted out of health dental only
if they have alternate coverage —
not because they don’t want to join!

“But my employees pay
50% of the premiums! I
can’t force someone to pay
this amount if they don’t
want to!”
Actually…you can, and you must.
Do you let employees opt out of other deductions such as CPP?
You can make the benefit plan mandatory of employment.
!
If you don’t want to have this discussion, don’t have employees
share the cost on payroll - instead, put in cost-sharing at the POS
like co-pays or deductibles.

“Ok…but I’ve been
operating for years under
this assumption. If they
join now, they will be late
applicants.”
Let us know and we can ask for approval
of an ‘open enrollment’ period if you agree
to enrol all employees onto the plan.

Patricia Thomas:
Benefits Audits
42

Refusal of Benefits Form
Spousal signatures are now required
!
Require an updated form every year
!
Do these forms stand up in court?
43

NEMs
Non-evidence maximums
!
Do your employees know what this is,
and have they applied?
44

LTD
Earnings definitions
!
Does your insurance policy earnings definition
match your company’s practices?
!
Usually coverage is only for base salary - not
bonuses, dividends, commissions or overtime.
45

Booklets
!
Do all employees have the most
up-to-date policy booklet
displaying coverage and
guidelines?
46

Plan Administrator
Liability Coverage
!
Does your business liability insurance
have a provision for plan
administration liability? If not, add it!
47

Claims
!
If you are processing claims on behalf of your
employees, stop!
!
You don’t want to be accused of a breech of
privacy, or a termination because you knew the
employee was sick because you saw their claims.
48

Questions about Coverage
!
Have the employee call the call centre, instead
of asking you, due to privacy.
!
The Co-operators 1-800-667-8164
Standard Life / Manulife 1-800-499-4425
Green Shield Canada 1-888-711-1119
49

Catastrophic
Drug Coverage
!
Ontario Trillium Drug
Program
50

MF/Situation: An employee has
been prescribed a drug costing
$50,000.
!
Your benefit plan has a 20% copay
= $10,000.
!
The employee’s salary is $40,000.
Now what?
51

Sick Leaves.

Short-Term
Disability

“Boss, I broke my
leg! I need 2
months off.”

“Boss, I need to take some
time off. Medical leave.
Maybe 2 weeks, but not
sure. I can try my best to
work from home.”

Do you…
A) Pay them full salary?
B) Pay them in full but
encourage them to work from
home?
C) Send them to EI but make a
one-time exception to pay
them the difference.

If you don’t have a WI/STD
plan:
!
- Set up a SUB plan as a
placeholder
- A SUB plan allows you to
top-up their EI payments
without any claw-backs

Short Term Disability / WI
0
25
50
75
100
WI
0
25
50
75
100
WI
Premiums
Claims

EI Premium
Reduction
Program

Long Term Disability
!
Let the employee deal with the
insurer directly: privacy, liability
!
Don’t let them work or earn income
during the elimination period

Benefits:
Terminating an
Employee

Scenarios
!
- Employee quits
- Terminated with cause
- Severance
- Let us know in advance:
LOA

Pharmacogenetics -
Personalized Prescribing
64

S
 
Personalized  
Prescription  
Plan

Your medications should be
helping you, not hurting you
S Adverse Reaction
S Effectiveness

We are all unique, and so is the way
we metabolize medications

Main factor that predicts medication
response: Genetics

Case Study – Sarah is an employee
who has severe clinical depression

Case Study – Jane is an employee who has
been diagnosed with breast cancer

What do both of these case studies have
in common?

What do both of these case studies
have in common?
Incompatibilities to medication
that make it difficult to
determine the right drug at the
right dose the first time

What is P3?
S P3: Personalized Prescription Plan
S An employee benefit that utilizes a genetic test to
predict medication compatibility
S Not a test to predict disease risk
S Confidential (information does not go to the
insurance company)
S Similar to an allergy test (information cannot hurt
you)

Beneplan Pilot Study –  
How does it work?
1. Enroll your company in Beneplan Pilot
Study
S At no cost to members
S Limited 6 month duration
2. Eligibility

You are eligible to requisition a P3 test if
you are on a medication that we test for
S We test for over 900 brand names of medications
S Psychiatric
S Oncology
S Cardiology
S Gastroenterology
S Pain
S Rheumatology
S Infectious diseases
S See the complete list of drugs at: www.personalizedprescribing.com

Other Questions?
S Call: 1 (844) 943 – 0210
S Email: info@personalizedprescribing.com
S 100% Confidential
S See Policy Letter in Beneplan Booklet for
more info

We are all unique, and so is the way we
metabolize medications

Evelyne
Mitskopoulos:
Wellness
in the
Workplace

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca

Disclaimer
The
advice
given
in
this
presentation
is
the
result
of

recommendations
from
medical
doctors
and

researchers
in
the
allopathic
and
complementary
health

community.

All
recommendations
are
based
on
clinical

evidence
and
studies
which
were
published
in
peer-‐
reviewed
journals.

Any
additional
advice
expressed
in
this
presentation
is

opinion.

Prior
to
making
any
changes
to
your
diet,
taking

supplements
or
exercising,
please
consult
with
your

medical
doctor.

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca

!
Warning:
The
information
you
are
about
to
receive

may
cause
you
or
your
employees
to
enjoy
their

Job.

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca

Root
causes
that
affect
work
performance
!
• Lack
of
physical
activity

• Inadequate
nutrition
(diet
high
in
fat,
starch

sugar)

• Chronic
Stress

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca

Barriers
affecting
Employees
1) Lack
of
Time

!
2) Lack
of
Motivation

!
3) Lack
of
Energy

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca

What
can
we
do
at
the
Workplace?
• Healthy
food
options
at
work

• Health
spending
accounts
e.g.
exercise
classes

• Employee
Assistance
Program
(EAP)

• Employers
need
to
be
flexible
with
Employee

e.g.
Time
to
allow
them
to
attend
exercise
class

• Rewards
for
accomplishments
e.g.
Prizes
to
walk
to

work
/
weight
loss
competition

• Health
day
exhibition
at
work
or
tickets
to
events

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca
How
to
get
Started?
• Surveys,
lunchtime
meetings,
posters

• Health
Risk
Assessments
conducted
by

companies
in-‐house
(Medisys)

• Wellness
committee
with
management
support

• Follow
up
in
6
mos.
to
measure
effectiveness

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca
• Know
your
demographics

• Know
your
attendance
rates

• Know
your
Data
-‐
drug
claims
experience
to
see

top
5
drugs
used
e.g.
antidepressants,
metabolic

syndrome
drugs,
painkillers

• Know
your
employees.

What
are
their
needs,

attitudes
and
preferences?

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca
What
is
the
Cost
of
Doing
Nothing?
• Increased
Employee
turnover

• Reduced
efficiency

productivity

• Higher
stress

• Every
$
spend
on
wellness
generates
$3-‐5
return
on

investment
(Source:
Benefits
Canada
)

• Giving
employees
tools
to
achieve
their
goals
and

stats
show
88%
success
rate
(Benefits
Canada)

• Budget
–
Employer
to
support
and
employee
can

raise
funds
such
as
dress
down
day
$2.00

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca
Protect
our
Brains
Reduce
sugars
and
white
refined
carbs.

These

foods
“caramelize”
the
coating
around
our
brain,

as
well
as
collagen
throughout
the
body.
(Source:

Optimum
Nutrition
for
the
Mind)

!
Add
lean
proteins
(fish,
eggs,
whey
protein
powder

contain
amino
acids
that
are
building
blocks
for

brain
chemical
messengers

stabilize
blood
sugar

levels)

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca
Omega
3
Fatty
Acids
(3,000
mg
daily)

• Decreases
inflammation
in
the
brain

central

nervous
system

• Ensures
adequate
healthy
fats
to
form
the
outer

coating
of
neurons,
and
helps
prevent
abnormal

plaque
buildup
that
contribute
to
several

neurological
conditions
and
impair
memory

(Source:
Optimum
Nutrition
for
the
Mind,

Patrick
Holford)

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca

Sleep
and
Melatonin
• Deep
sleep
(REM),
7-‐9
hours
nightly
for

cognition,
memory
and
tissue
repair

• Melatonin
–
before
bedtime
3
mg,
regardless
of

sleep
patterns,
is
a
powerful
free
radical

scavenger
and
anti-‐inflammatory
for
the
brain.

– Most
important
nutrient
for
prevention
of
Dementia

and
Alzheimer’s
(Source:

Mind
Over
Matter
–

Women’s
Brain
Health
Initiative)

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca
Meditation
• Increases
delta
wave
activity

(calm
brain
wave
in
stage
4
sleep)

• Inhibits
cortisol
production

• Improves
blood
flow

• 15-‐30
minutes/day
for
8
wks

• Improves
hippocampal
activity
(key
area
of
brain
that

shrinks
in
dementia)

• Improves
short-‐term
memory,
focus,
cognitive
function,

neural
connectivity

transmission

• (Source:

Mind
Over
Matter
–
Women’s
Brain
Health
Initiative)

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca

Sitting
Disease
• Canadian
adults
spend
¾
of
their
waking
hours
each
day

sitting
or
reclining

children
2/3
being
sedentary

• Body’s
tissues,
organs
and
metabolism
aren’t
engaged,

heart,
lungs

muscles
go
into
hibernation
and
atrophy

• Simply
standing
up
over
30
times
a
day
is
a
powerful

antidote
to
long
periods
of
sitting
and
is
more
effective

than
walking
-‐
it’s
how
often
you
interrupt
that
sitting

that
is
GOOD
for
you

• Ex:
housework,
gardening,
cooking,
photocopier,
and

even
just
standing
up
every
10
minutes

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca
Vitamins
– 

an
essential
part
of
healthy
living
• Vitamin
C
–
strengthens
blood
vessel
walls,
prevents

infection

aids
in
body’s
recovery

• Vitamin
D
–
“sunshine
vitamin”,
strengthens
bones

(calcium
absorption),
increases
immune
system,
brain

health

• B
Vitamins
–
helps
to
regulate
body’s
energy,
blood

sugar

antioxidant
mechanisms.

For
strong
immune

system,
red
blood
cell

antibody
formation,
vision

healthy
skin

• Vitamin
E
–
body’s
defense
against
illness
and

disease,
and
chronic
stress

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca

Vision

Eye
Twitches
• Take
frequent
eye
breaks
every
20
minutes

• Reduce
glare
from
windows
or
lights
by
repositioning
computers
and

using
dimmer
lights

• Use
a
screen
filter,
or
control
screen
contrast
to
cut
down
on
glare

• Wear
sunglasses
or
hat
in
bright
sunlight

• Discuss
your
medications
with
Eye
doctor
as
they
can
further
damage

health
of
your
eye
(especially
epilepsy

psychosis
drugs)

• Use
moisturizing
eye
drops
to
lubricate
irritated
eyes

• Sleep
adequately.
Reduce
caffeine
and
alcohol.

Do
not
smoke.

• Compress
of
warm
water
sterile
pad

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca
Scalene
• Muscles
on
side
of
neck

• Also
known
as
a
group
of
respiratory
muscles

• They
respond
or
react
to
the
breathing
pattern

• Necessary
for
your
diaphragm
to
go
up
and
down
with

inhalation
and
exhalation

• Taking
short
breathes
due
to
stress
response
inhibits

diaphragm
movement
and
scalene
tighten

• When
tightened
can
cause
headaches,
neck
pain
and

over
time
discs
clamp
down
causing
degenerative
disc

disease

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca
Stress

Anxiety

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca

Laughter
–
What
a
way
to
Go!

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca
Why
is
Nutrition
so
Important? 
Now
vs
100
years
ago…
Less
Nutrients
available
because:

• Soil
depletion

• Artificial
fertilizers

• Sterile
soil

• Fruits

vegetables
picked
unripe

• Transportation

storage
of
foods
degrade

• Irradiation

• Processed/junk
foods

• Less
raw
foods,
more
cooked

• Poor
digestion

absorption

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca
When
all
else
fails
here
is
your
prescription…

Evelyne
Mitskopoulos,
Director
of
Wellness,
Beneplan
Inc

1
(800)
387-‐1670
x
226
evelyne@beneplan.ca

To
book
a
wellness
lunch

learn
at
your
company,

please
contact:

!
Evelyne
Mitskopoulos
CNP

Evelyne@Beneplan.ca

1-‐800-‐387-‐1670
x226

!
There
is
no
charge
for
members
of
the
co-‐operative.

Martin Walker -
The Co-operators Life
103

Reformulary Results 2015
Average - Beneplan block April 1 2015 to October 31 2015
n=2,134 employees and dependents
116
Reformulary
Generic
Substitution

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!
~ Overview Presentation – 1 December 2015 ~
!
Beneplan: Annual Plan Administrator's Workshop

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A
Lesson
in
Winning
Drug
Plan
Design
with
Reformulary
✓ YEAR
1
SAVINGS:
drug
spend

decrease
to
$75,300

✓ YEAR
2
SAVINGS:
drug
spend

deceased
further
to
$72,800

✓ ENGAGED
EMPLOYEES
Case
Study
Restaurant
Chain

✓195
lives

✓$83,000
drug
plan
spend
 
pre-‐Reformulary

✓Implemented
the
Reformulary
in

2013

!
!
RESULTS
28%
savings
“We
recognize
our
drug
plan
as
an
investment
in
the

overall
health
and
well-‐being
of
our
people.
Our
drug

plan
encourages
our
employees
to
be
engaged
and

make
sensible
choices
about
the
prescription
drugs
they

are
taking.”

“A
benefit
plan
that
reflects
our
culture
is
important…

and
a
good
prescription
drug
plan
is
a
big
part
of
it.”

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Impact
of
new
Hep
C
drugs
on
actual
employer
plan
✓ SAVINGS:
Net
of
dispensing
fee,
plan

spend
was
$1.5
million

✓ HEP
C:
Increase
in
hep
C
spend,
from

$476
to
$176,000
for
0.07%
of

members

✓ MANAGE:
16.1%
savings
offset

increased
specialty
drug
spend…
Case
Study
B2B
Employer
Plan

✓2,200
lives

✓$2
million
drug
plan
spend
 
pre-‐Reformulary

✓$111,919
spent
on
biologics
 
for
0.23%
of
members

✓Implemented
the
Reformulary
in

2014

!
!
RESULTS
7.4%
net savings

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120
The
case
for
a
smarter
drug
plan
1.
Higher
cost
drug
claims
are
having
a
material
effect
on
insurers
and

employers,
with
employers
carrying
most
of
the
incremental
increase

through
increased
pooling
rates

!
2.
When
drug
plans
are
well-‐designed,
employees
can
become
informed
and

involved,
and
make
choices
consistent
with
contributing
to
the
long-‐term

sustainability
of
the
plan

!
3.
Drugs
are
the
most
expensive
benefit
in
your
health
benefit
plan;
current

drug
plans
are
not
providing
maximum
value
for
money

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121
The
Reformulary
The
Reformulary®
is
an
innovative
“formulary”
(or
list
of
drugs),
built

based
on
evidence.
Our
formulary
uses
tiers
and
co-‐pays
to
promote

drugs
that
provide
the
best
healthcare
value.
By
encouraging
employees

to
use
similarly
effective
drugs
that
are
the
most
affordable,
this
ensures

long-‐term
sustainability
of
your
drug
plan

!
Clients
have
realized
savings
of
between
9%
and
15%
in
drug
spend
Our
partners
Other
channels

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1.
We
do
the
homework
We
review
all
drugs,
and
we
actively

monitor
new
drugs
coming
to
market

!
Each
drug
on
our
formulary
has
been

evaluated
by
an
impartial

independent

Expert
Committee,
comprising
practicing

physicians
and
pharmacists.
They
evaluate:

•Clinical
effectiveness

•Cost-‐effectiveness

•Real-‐world
evidence
(patient
experiences
in
the
real-‐
world)

!
Our
evidence-‐based
review
process
is
more

than
4
years
old.
We
manage
it
using
an

international
patent-‐pending
process
Based
on
this

evidence-‐based

review,
we

categorize
drugs
as

preferred
and
non-‐
preferred,
with

different
 
co-‐pays…
WHAT
WE
DO
(behind
the
scenes)

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Drugs
that
offer
the

best
healthcare
value,

and
are
always
the

most
affordable

(lowest
member
co-‐
pay)
Preferred
drugs (tier 1)
Drugs
that
provide
less

healthcare
value
than

preferred
drugs.

For
every
non-‐preferred

drug,
there
is
a
clinically

similar
alternative
on
tier

1
at
lowest
co-‐pay
Non-preferred
drugs (tier 2)
Non-preferred
drugs (tier 3)
Drugs
that
provide
the

least
healthcare
value,

and
have
the
highest

member
co-‐pay.

For
every
non-‐preferred

drug,
there
is
a
clinically

similar
alternative
on
tier

1
Preferred
and
non-‐preferred
drugs

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High
cost
specialty
drugs
are
reviewed
by
our
Expert
Committee.
We

prepare
detailed
clinical
criteria
based
on
evidence,
as
to
which
drugs

are
most
appropriate
for
which
groups
of
patients.
Drugs
such
as:

!
Sovaldi

|
Harvoni

|
Vimizim

|
Kalydeco

|
Inflectra
|
Praluent*
|
Repatha

!
These
drugs
require
prior
approval,
meaning
that
members
must
meet

the
specific
clinical
criteria
in
order
to
be
approved
for
coverage

Impactful
management
of
specialty
drugs
* Not yet approved in Canada; will be reviewed by our Expert Committee and likely only available via Special Authorization

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125
Impact
of
one
drug
(PCSK9
Inhibitor)
on
total
plan
costs
over
3
years
$22,974
$23,384
$31,412
$229,792
$223,845
$314,116
$459,484
$467,698
$628,231
37%
INCREASE

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All-‐in-‐One
Benefit
from
our

negotiating
power

!
Generic

substitution
Therapeutic

alternatives
Communication
 
tools,
including

DrugFinder
Special
authorization

for
specialty

high

cost
drugs
2.
Employer
communicates
just
one
change
Quantity
limits;

Step
therapy

!
WHAT
YOU
DO

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127
To
ensure
a
smooth
transition,
plan
members
get
access
to
these

engagement
tools
…
We
make
it
easy
for
people
to
switch
Dr Mike video
Most
members
are
not
impacted
by
moving
to
the
Reformulary

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Tells
employees
exactly
what
drugs
are
covered,
on
which
tier,
and
at
what
co-‐pay

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131
3.
Best-‐In-‐Class
Experience

Results.

Company
Drug
spend Number
of
claimants Plan
savings Generic
penetration
Return
on
Investment

(ROI)
Employer
A
$

5,264,207
10,779 9% 83% 1711%
Employer
B
$

7,043,802
18,305 9% 82% 1141%
Employer
C
$

75,272
195 28% 65% 200%
Employer
D
$

411,288
850 9% 81% 473%
Employer
E
$

4,968,283
9,467 7% 82% 1293%
Employer
F
$

1,495,065
3,070 18% 79% 1650%
Employer
G
$

428,693
1,067 8% 79% 401%
Employer
H
$

90,411
218 9% 81% 160%
Employer
I
$

219,582
543 39% 77% 2346%
Notes

Number
of
claimants
includes
employees
and
dependents
that
made
a
claim

Savings
percentage
based
on
Per
Member
Per
Month
(PMPM),
based
on
drugs
tiered
on
the
Reformulary

Generic
penetration
refers
to
rate
at
which
generic
drug
is
substituted
(dispensed)
in
place
of
the
original
brand
name
drug

Generic
fill
rate
refers
to
the
number
of
prescriptions
for
generic
drugs
as
a
percentage
of
all
prescriptions
dispensed

Plan
members
taking
preferred
drugs
refers
to
the
percentage
of
prescriptions
by
members
for
preferred
drugs

Return
on
Investment
(ROI)
is
calculated
as
the
cost
of
subscribing
to
the
Reformulary,
minus
the
savings,
divided
by
the
cost
WHAT
YOU
GET

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Our
offerings
What: Interactive tool for members to look up preferred non-‐
preferred drugs, and drug alternatives | Enables more affordable
choices for Canadians
!
!
Who: Offered to all Reformulary Reformulary Select clients
What: Same great formulary | Delivers meaningful savings |
Preferred (no or little co-‐pay) and non-‐preferred drugs (higher co-‐
pay) | All members grandfathered on implementation so no
member impact | Access to DrugFinder to encourage member
behavior change
!
Who: Small to medium businesses; association plans; unions
What: Evidence-‐based formulary | 100% track record of delivering
savings to clients (typically 9 to 15%) | Preferred (no or little co-‐pay)
and non-‐preferred drugs (higher co-‐pay) | Personalized
communication to members access to DrugFinder successfully
effects member behavior change
!
Who: Corporate Canada

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Potential
next
steps
ReModel – quick estimate of your potential
savings based on implementing the
Reformulary; models top 100 DINs (no fee)
Full Model – detailed, claims level modelling
of potential savings member impact based
on implementing the Reformulary (fee)

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1. All
drugs
on
the
Reformulary–
and
new
drugs
coming
to
market
–
are
reviewed

by
experts.

2. Our
Expert
Committee
is
credible,
unbiased
and
independent.

3. The
Reformulary
includes
all
drugs.

4. We
already
found
the
best
price.

5. We
create
informed
consumers.

6. Our
results
speak
for
themselves.

!
!
There
is
no
other
offering
in
the
market
as
comprehensive
and

proven
as
the
Reformulary.
In
summary…

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Hammond Power Solutions:

Innovation in its drug plan design

!
Hammond Power Solutions is the largest manufacturer of electrical dry-type transformers and
related engineered magnetic devices in North America. A family-owned business for over 97
years, Hammond Power has grown into an industry leader with 1,400 employees, 12
manufacturing facilities and 8 regional warehouses.
!
“Being more open to change and looking for better ways” – innovation – is one of five core values
at Hammond Power. That innovation extends into employee health benefits, whereby the
company provides benefits to both its union and non-unionized staff, including extended health
care and prescription drug benefits. Hammond Power was looking for better ways to provide
prescription drug benefits, offering the best possible value while encouraging members to
become more involved in their drug and health decisions.
!
In October 2014, Hammond Power seamlessly implemented the Reformulary® within their
salaried employees. Marta Dawe, Human Resource Manager, commented on the smooth
implementation with members actively using DrugFinder. She states, “We are very pleased
overall with the implementation of the Reformulary. We followed a step-by-step, phased launch
approach established by our insurance provider and Reformulary Group that made for a trouble-
free transition. Communication to members was personalized, thorough and easy to understand.”

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Trillium Health Partners creating a “new kind of healthcare”, which includes the Reformulary
!
Trillium Health Partners is a leading hospital in Canada with an outstanding record of performance, fiscal
responsibility, and quality patient care. The hospital encompasses the Credit Valley Hospital, Mississauga
Hospital, and Queensway Health Centre. Trillium Health Partners has set out a vision and plan to create
a “new kind of healthcare for a healthier community”, with goals to achieve quality, access, and
sustainability.
!
With an organization-wide commitment to quality, access, and sustainability, Trillium Health Partners
was looking for ways to achieve greater employee choice and long-term sustainability from its drug
plan. After careful consideration, Trillium Health Partners made the decision to implement the
Reformulary as a part of the benefits plan for non-unionized staff. Drug plans powered by Reformulary
are structured and managed to maximize value and encourage coverage of drug products that are
effective, safe and cost efficient.
!
Karli Farrow, Vice President, Strategy, People, and Corporate Governance explains, “When we sat down
and looked closely at the modeling that Reformulary provided, we saw opportunities to provide better
value in our drug plan to members. This aligns with our record of fiscal responsibility and providing
quality benefits to our staff.”
!
The first hospital in Canada to implement, Trillium Health Partners successfully implemented the
Reformulary on January 1, 2015. Today, these Trillium plan members have access to DrugFinder to
become more engaged in their health care decisions by choosing preferred drugs in their plan.

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Reformulary
Results
2014

!
•Smooth
implementation

!
•9.4%
savings,
per
member
per
month

!
•Engaged
employees
Real
Estate

150
lives

!
•Medium
sized
real
estate
company

!
•Management
considered
Reformulary
over
a
year
ago,

BUT...

!
•…were
concerned
about
rocking
the
boat

!
•“We
did
some
cost
projections
on
the
demographics
of

our
employee
base
and
drug
spend.
We
were
concerned

about
our
plan's
sustainability
—
and
knew
we
needed

to
act
quickly”

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University

2,700
lives

!
•University
provides
negotiated
healthcare
benefits
to

unionized
faculty
and
staff,
as
well
as
salaried
staff

!
•University

OPSEU
in
bargaining
in
2014.
University

looking
for
ways
to
achieve
greater
value,
and
open
to

new
or
improved
benefits
that
are
‘cost-‐manageable’.

OPSEU
had
requests
for
improved
benefits
in
certain

areas

!
•Successfully
bargaining,
and
implemented

!
•University
now
tabling
with
another
union
Results
To-‐date

!
•Smooth
implementation

!
•Participated
in
town
hall
meeting
with

200
OPSEU
members

!
•“…both
the
members
in
attendance

and
I
found
it
extremely
informative
…
feedback
from
members
has
been
for

the
most
part
quite
position”

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National
Freight
and
Courier
Service

2,000
lives

!
•Recent
downsizing.
Employee
survey
identified
that

employees
placed
little
value
on
the
company’s
health

and
dental
plans

!
•Company
determined
that
plan
was
not
competitive

and
needed
major
improvements
in
order
to
better

engage
and
provide
value
to
employees

!
•Company
wanted
to
align
their
drug
plan
with
two
of

the
company’s
values:
‘People
first’
and
‘transparency’
Reformulary
Results
2015

!
•Smooth
implementation

!
•Engaged
employees

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Reformulary
Group
Inc.

55
York
Street
|
Suite
1400
|
Toronto,
ON
|
M5J
1R7

!
!
www.reformulary.com

!
http://www.reformulary.com/index_en.php?page=drugfinder

Mark Faiz
Chairman
mfaiz@beneplan.ca
!
Vince Principato
President
vprincipato@beneplan.ca
!
Yafa Sakkejha
GM
yafa@beneplan.ca
!
The Beneplan Co-operative
150 Ferrand Drive Suite 500
Toronto Ontario M3C 3E5
1.800.387.1670
beneplan.ca
142
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