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CLHIA Launches Drug Pooling Agreement

The Canadian life/health insurance industry has announced an industry-wide drug pooling agreement to help mitigate the impact of high drug costs on fully insured employer drug plans.

 This plan allows insurers to sustain group drug benefit programs in the event that one or more of a group's employees has a recurring, very high cost prescription drug claim. The framework was developed under the leadership of the Canadian Life and Health Insurance Association (CLHIA) and Canadian health insurers.

Coming into effect on January 1, 2013, the agreement will apply to fully insured drug plans only, not ASO, refund accounting or stop-loss plans. The industry felt the most effective way to way to begin to address drug pooling challenges, was to select a segment of the market that was completely within the scope of the life and health insurance industry, i.e. fully insured plans.  The industry may decide to extend this agreement to cover other types of employer plans at a later date; however doing so at this stage would have significantly increased the complexity of putting this agreement in place and delayed implementation.

The pooling agreement is comprised of 2 components:

Participating insurers have to place all high cost drug claims from all their fully insured group drug business in internal pools, subject to certain exceptions pre-defined in the agreement. The internal pooling arrangement must comply with a set of minimum standards, the key requirement being that insurers cannot set a plan sponsor’s insurance pooled premiums with any reference to the number or size of any high cost claims that are being pooled.  In essence, insurers are required to set the premium assuming that the high cost pooled claims did not exist.  Beyond the basic standards, all aspects of the internal pools will be open for customization by each insurer.

To help each participating insurer sustain the costs of offering this pooling protection to their clients, the industry has also agreed to set up an industry-wide pooling framework to spread the risk of recurrent, high cost prescription drug claims across all participating insurers. 

The agreement helps shield plan sponsors and plan members from the full impact of high cost claims. By having the high claims protected by pooling, plan sponsors will not have to resort to restricting reimbursement for expensive drugs, which means that plan members will not risk being left without coverage when they need it most.  It also allows these plan sponsors to access a fully competitive market for their group business and not be tied to their existing group insurance provider as is sometimes the case today. 

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