Medical marijuana – where do we go from here?

January 9, 2018

Although we have written a feature on this before – see The Inside Story® from December 2014 – we want to revisit the issue of medical marijuana and its inevitable expansion into health benefits plans in ways beyond the route it takes today – namely reimbursement under health care spending accounts (HCSAs). And we specifically want to let GSC plan sponsors know how we will let them decide on this question in 2018. But you’ll have to read to the end – well, OK, if you’re the impatient type, you can flip to the end of this article to see what’s happening there.

Medical marijuana coverage today

For us in the health benefits world, one of the most vexing issues about medical marijuana is the fact that Health Canada has not approved the plant as medicine, nor issued a drug identification number (DIN) for it – something that every drug on our industry’s formularies possesses.

But despite all that, Canadians are using medical marijuana today. And we reimburse them through HCSAs. What’s the process for a patient to gain access today? First, a physician needs to complete a specific form detailing the quantity of marijuana their patient is authorized to use, the strain of the plant, and the period of use. The product is then sent to the patient by a licensed producer via mail order. There are different products for a physician to select from and different ways for a patient to ingest it (smoke, vaporize, ingest, apply topical creams, etc…). And, as a rule, it currently costs $8–12 a gram depending on the licensed producer and the product. We reimburse claims based on these standards.

A brand-new world – what are plan sponsors to do…?

Well, actually, a lot… or a little… or nothing at all. There will definitely be many viewpoints on this. But here
are some considerations when assessing the addition of medical marijuana to a benefits plan in a broader (than HCSA) way:

1. This is not the silver bullet for the opioid epidemic. Current treatment guidelines see the prescribing of medical marijuana as an add-on to opioid treatment, not a replacement. Further, any evidence to suggest opioid use may decrease with the usage of medical marijuana is suggestive at best.

2. With the legal use of marijuana on our horizon, the potential for diversion from medical to recreational
use increases.

3. There are known health impacts with the use of marijuana – for medical or recreational purposes. These include a number of short-term effects (loss of balance, confusion, drowsiness, nausea, to name a few), as well as long-term psychoactive and neurocognitive impacts that are not fully known at this point.

4. This is not projected to be a low-cost benefit. If we assume an average cost of, say, $9 per gram1, and an average patient uses three grams per day, that plan member could approach $10,000 in costs annually. By GSC standards, this is entering the high-cost claimant category.

5. And an always pertinent topic at GSC – the research for most of the current usage of medical marijuana is
generally lacking in both quantity and quality.  However, having stated that, there is more research and evidence that has emerged for some medical indications over others, specifically neuropathic pain and some side-effects related to multiple sclerosis and cancer.

These cautionary tales are not meant to suggest coverage of medical marijuana should be ruled out in benefits plans. Sufferers of the three disease states noted above (and, inevitably, other conditions), will be looking to plan sponsors for answers on the availability of medical marijuana, and we believe it is appropriate for us all – advisors, sponsors, carriers – to seriously consider how we can support these patient communities.

GSC to offer plan sponsors an option for medical marijuana reimbursement in 2018

Come early 2018, GSC will introduce a new product for our plan sponsors that will offer more options for incorporating medical marijuana into benefits plans, but with a much greater level of oversight and rigour than is currently available through HCSAs. Here are a few general specifications:

  • Medical marijuana will be a benefit offered under extended health care coverage, not the drug benefit –
    remember there is no DIN.
  •  Above we noted the cost of this product; so no surprise that there will be benefit maximums put in place. They are currently under construction and the entire pricing impact of the benefit will be available for consideration in the new year.

To receive reimbursement, claimants will have to follow a prior authorization process with criteria based on specific medical conditions.
What specific medical conditions? To start, coverage will be limited to:

  • Chronic neuropathic pain
  • Spasticity due to multiple sclerosis
  • Nausea and vomiting due to cancer chemotherapy

These were chosen based on the best available research today. The number of eligible conditions is likely to increase over time based on the emerging evidence, and will be communicated by GSC to plan sponsors when, or if, that occurs.

So, we hope you consider this issue of Follow the Script an end-of-year present. It’s meant to provoke some serious thought, maybe even debate, over the holiday season. Perhaps those discussions will be fueled by substances fully legal – beer, wine, and other spirits – but we know our readership would NEVER test drive other products that still fall on the wrong side of the law. (July, people, it’s July.)

See you in the new year!

Source: 1Solomon Israel, “How high will the price of legal pot be?”, CBC News, April 1, 2017. Retrieved: December 4, 2017.