Benefits Q&A: Sorry, medical marijuana is not covered

HSA REPORT, DECEMBER 2014

by Dennis Blatchford, Pensions and Benefits Advocate

I'm advised by Pacific Blue Cross that fertility drugs are not covered under the new 50 per cent cost share arrangement for non-PharmaCare formulary medications. Why are these drugs not covered?

The agreement on the 50/50 cost share on non-PharmaCare formulary medications did not sweep in classes of drugs previously unavailable under the old drug plan. It was never the intent of the 50 per cent cost share language to include the so-called "lifestyle/supplementary" drugs that were not part of the pre-June 2013 Health Sciences Professionals (HSP) drug plan. Fertility drugs fall under the "lifestyle/supplementary" category; a catch-all term for certain medications deemed not medically necessary. Anti-obesity and sexual dysfunction medications also fall under this category of drugs and are not included in the HSP drug plan. These exclusions are quite typical of most drug plans in Canada.

It is important to remember that the 50 per cent cost share language was negotiated to provide reasonable access to medications not covered under the PharmaCare drug formulary. These medications were previously available under the old HSP drug plan when members enjoyed an open drug formulary – save and except the "lifestyle/supplementary" class of medications.

That changed when many unions were forced into accepting a limited formulary under the PharmaCare tie-In in early 2013. During the subsequent dispute over the botched implementation of the PharmaCare tie-In HSA pushed for improvements and achieved the 50 per cent language. This was included in the five-year extension of the collective agreement ratified last year.

What about medical marijuana? Does that fall under the "lifestyle/supplementary" class of drugs as well?

Actually, medical marijuana doesn't currently have a Notice of Compliance issued by Health Canada and therefore is not considered a prescription requiring drug. So it doesn't fall under any drug category; whether in the drug formulary or not. However, the courts have required reasonable access to a legal source of medical marijuana when authorized by a physician. Note that medical marijuana is authorized rather than prescribed by a physician. So, unless the status of medical marijuana changes, this product won't be part of any provincial drug formulary under current rules.

Meanwhile, 23 US states have voted to relax the laws on medical or recreational use of marijuana – despite still being illegal federally. These are trends that drug plan designers and health policy regulators will be watching closely in 2015.