Private drug plan leadership: vaccine coverage report card 2023
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Recent research conducted by Mapol Inc. highlights the industry-leading benefits providers, with vaccine coverage as a standard inclusion within group health and personal health insurance plans in Canada
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THE INAUGURAL Private Drug Plan Leadership: Vaccine Coverage Report Card was developed to highlight those benefits providers with modernized drug plan policies that include vaccines as a standard inclusion, rather than leaving the drug plan decision in the hands of the plan sponsor or benefits advisor.
The World Health Organization (WHO) states that immunization is the foundation of the primary health care system and an indisputable human right. It’s also one of the best health investments money can buy. Yet, despite tremendous progress, far too many people around the world have insufficient access to vaccines.
Mapol Inc. is the pharmaceutical industry's leading market access expert on private and public payer drug plans in Canada. With over 100 years of combined experience within both the pharmaceutical and payer industries, our products and services are tailored to meet the needs of those working for pharmaceutical manufacturers in the areas of market access and product reimbursement.
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Vaccine Policy Grading Scale
“We celebrate the health benefits providers leading the industry with vaccine coverage as a standard inclusion and challenge the remaining providers to modernize their policies to improve coverage for their plan members”
Johnny Ma,
Mapol Inc.
In Canada, access to and funding of vaccines is comprised of a complex mix of provincial/territorial public health programs, private payer plans, and out-of-pocket cash. While many vaccines are available in Canada for both children and adults, the success of vaccine uptake and adherence to immunization guidelines seen in children has not been observed among
adult Canadians.
Currently, there is no obligation for Canadian provinces, territories, federal governments, or private payers to cover adult vaccines that have been recommended by the National Advisory Committee on Immunization (NACI). Consequently, the availability of vaccine coverage across Canada is patchy and inconsistent for certain diseases. One province may provide and deliver a NACI recommended vaccine as part of
its publicly funded provincial health program, while another provides no funding, limiting access to those who are aware of the vaccine and have the ability to pay for it.
In 2022, Canadian insurers paid out a record $114 billion in benefits – up $11 billion from pre-pandemic levels. This included nearly $44 billion in health benefits, of which $14.3 billion was paid on prescription drug claims. However, research conducted by Mapol has shown 32 percent of private payer plan members do not have coverage for vaccines, and 31 percent of private payer vaccine prescription claims are rejected, leaving plan members with insufficient coverage and unnecessary out-of-pocket costs. Furthermore, this research has shown that benefits plans covering all vaccines incur costs amounting to approximately two percent of the overall private drug plan spend, with an average of 1.5 claims per year and an average claim cost of $91.14.
When Mapol polled over 200 individuals working in the private payer industry, over 95 percent answered they would prefer to pay to “prevent an illness” vs. pay to “treat an illness.” Vaccines work by building up the individual’s immune response and inherently help prevent severe illness.
So why do private benefits providers continue to ask plan sponsors if they wish to cover vaccines as an option? Many benefits providers have already taken the leadership position to include vaccines within their standard plan. For plan sponsors who wish to provide vaccine coverage and protection to their plan members, the report card will serve as a useful tool when discussing this topic with their benefits advisor/broker at the next renewal. For Canadians who do not have access to group benefits plans, the report card will help them compare and choose the best personal health insurance (PHI) providers with access to vaccines across all their plans.
“Vaccination is a safe and effective way of protecting your workforce (and their family members) against harmful diseases before they contract them. In a perfect world, government would provide universal vaccine coverage for all Canadians, but this is not the world we live in today. I challenge plan sponsors, advisors, and plan providers to make non-publicly funded vaccines a mandatory and normal part of all private payer drug plans. The inconsequential increase in claims cost for meaningful vaccine coverage is eclipsed by the economic and social cost of preventable illness and recovery”
Gordon R. Hart,
Selectpath Benefits & Financial Inc.
Mapol worked with industry experts in group benefits and personal health insurance policies to develop this report card. The goal of this research, on the group benefits side, was to identify what drug plan design would be offered to a potential plan sponsor with no previous history. For example, would the plan include vaccines as a standard inclusion, or would the benefits provider ask the plan sponsor if they wished to include vaccines? With the help of two benefits consultants, Gordon R. Hart at Selectpath Benefits & Financial Inc., and Dave Patriarche at Mainstay Insurance Brokerage Inc., we surveyed benefits providers from August to October 2023 about their policy on vaccine coverage within their group plans. We also looked at the vaccine coverage in PHI plans with the help of Evan Morgan, founder of CompareHealth Inc., an online platform that makes quoting and comparing PHI plans easy for advisors in Canada.
Only two out of the 17 benefits providers included in this research had Grade A vaccine coverage in all of their group benefits and personal health insurance drug plan offerings. Congratulations to Sun Life and GreenShield for their leadership positions in making vaccines a standard inclusion in all their drug plans for new plan sponsors and plan members with no prior history.
There is a clear need for many of the benefits providers with suboptimal vaccine coverage within their group and PHI plans to modernize their policies in order to ensure consistency in vaccine access for private plan members across Canada.
Recommended but unfunded vaccines leave adults in Canada more vulnerable to vaccine-preventable diseases (VPDs) – especially older adults who are more susceptible to severe health outcomes caused by VPDs, and those who are not able to pay for recommended but unfunded vaccines out-of-pocket. In efforts to create diverse workplaces that promote diversity, equity, and inclusion (DEI), ensuring access to vaccine-preventable diseases for more vulnerable populations is critical.
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Patchy and inconsistent coverage
Key Findings
Published 27 November 2023
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“Vaccines help people take a proactive approach to their overall health, and conversations about the importance of vaccines have become more prevalent for Canadian families. I congratulate the many personal health insurance (PHI) providers that recognize this importance and cover vaccines across all plans. With some PHI providers, vaccines are an up-sell to a more expensive plan/option or categorized as a lifestyle drug. For these providers, the solution is simple and easy: make vaccines a standard inclusion in all PHI plans”
Evan Morgan,
CompareHealth Inc.
Criteria for Grade
Grade
Group Benefits
Personal Health Insurance
Grade A – vaccine coverage leaders
Vaccines are a standard inclusion with no maximums recommended.
All health plans with prescription drug coverage (whether included or an optional benefit) cover vaccines with no maximums on vaccines specifically. Overall drug maximums may apply.
Grade B – vaccine coverage with annual maximum over $500
Vaccines are a standard inclusion with an annual vaccine maximum over $500.
All health plans with prescription drug coverage (whether included or an optional benefit) cover vaccines with an annual maximum of at least $500.
Grade C – vaccine coverage with annual maximum under $500
Vaccines are a standard inclusion with an annual maximum on vaccines under $500.
All health plans with prescription drug coverage (whether included or an optional benefit) cover vaccines with an annual maximum under $500.
Grade D – vaccine coverage optional
Vaccines may be covered when requested by plan sponsor or when option is selected.
A provider offers vaccine coverage with some of its health plans or prescription drug options, but not others.
Grade E – vaccine coverage not available
Does not apply to group plans since vaccines can be added if requested by plan sponsor.
Vaccine coverage excluded in all drug plan options.
Ranking of Benefits Providers by Vaccine Coverage Policy
(Sorted by grade and size of market by health premiums reported as of Dec. 31. 2022)
Ranking
1
Health Benefits
Provider
Grade for Group Benefits (90% weight)
Grade for PHI
(10% weight)
Sun Life
A
A
2
GreenShield
A
A
3
Desjardins
A
C
4
Group Medical Services
A
D
5
Saskatchewan
Blue Cross
A
E
5
Saskatchewan
Blue Cross
A
E
6
Empire Life
A
-
7
RBC Insurance
A
-
8
Alberta Blue Cross
C
A
9
Beneva
C
D
10
Pacific Blue Cross
D
A
2
1
3
There are multiple reasons for this gap in private payer vaccine coverage. First, many historical drug plan management policies classified vaccines as a “lifestyle” or “optional” drug category. Why is that? Many vaccinations were historically developed for childhood immunizations and were mostly funded by public health programs. Private benefits providers placed vaccines into an “optional” drug category to minimize their risk of paying for these claims. When plan sponsors set up their drug plans, the benefits provider would start with the “standard plan” offering and ask which “options” the plan sponsor wished to add. Some plan sponsors chose to include vaccines, whereas others did not. Over time, these options would be carried forward to the next benefits provider or insurance carrier, and hence a “legacy” of coverage was established. Fast forward to 2023, many vaccines are now approved for use in adults and many more are in development.
The Vaccine Coverage Report Card
1.
2.
3.
Financial support was provided at arm’s length to this project. The partners that funded this project did not have control over this report’s findings, content, or creative.
Sponsorship disclosure
1
2
3
4
World Health Organization. Immunization Agenda 2030: A Global Strategy to Leave No One Behind.
Parkins MD, et al. (2009). Routine immunization of adults in Canada.
Liu ZC et al. (2014). Herpes zoster vaccine (HZV): utilization and coverage 2009–2013, Alberta, Canada.
Canadian Life & Health Insurance Facts. 2023 Edition.
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“Vaccination is a safe and effective way of protecting your workforce (and their family members) against harmful diseases before they contract them. In a perfect world, government would provide universal vaccine coverage for all Canadians, but this is not the world we live in today. I challenge plan sponsors, advisors, and plan providers to make non-publicly funded vaccines a mandatory and normal part of all private payer drug plans. The inconsequential increase in claims cost for meaningful vaccine coverage is eclipsed by the economic and social cost of preventable illness and recovery”
Gordon R. Hart,
Selectpath Benefits & Financial Inc.
“Vaccines help people take a proactive approach to their overall health, and conversations about the importance of vaccines have become more prevalent for Canadian families. I congratulate the many personal health insurance (PHI) providers that recognize this importance and cover vaccines across all plans. With some PHI providers, vaccines are an up-sell to a more expensive plan/option or categorized as a lifestyle drug. For these providers, the solution is simple and easy: make vaccines a standard inclusion in all PHI plans”
Evan Morgan,
CompareHealth Inc.
Copyright © 2023 KM Business Information Canada Ltd.
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Copyright © 2023 KM Business Information Canada Ltd.
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11
Manulife
D
D
Approximate % of
Health Benefits Market (Nationally)
19%
9%
10%
<1%
<1%
2%
<1%
<1%
10%
<1%
17%
12
Medavie Blue Cross
D
D
4%
13
iA Financial
D
D
4%
14
Canada Life
D
E
22%
15
Equitable Life
D
E
1%
16
Co-operators
D
E
<1%
17
Manitoba Blue Cross
D
E
<1%
Top 10 ranking of benefits providers by vaccine coverage policy
(sorted by grade and size of market by health premiums reported)
Ranking
Health Benefits
Provider
Grade for Group Benefits (90% weight)
Grade for PHI
(10% weight)
1
Sun Life
A
A
2
GreenShield
A
A
3
Desjardins
A
C
4
Group Medical Services
A
D
5
Saskatchewan
Blue Cross
5
Saskatchewan
Blue Cross
A
E
6
Empire Life
A
-
7
RBC Insurance
A
-
8
Alberta Blue Cross
C
A
9
Beneva
C
D
10
Pacific Blue Cross
D
A