Six practical considerations for medical marijuana coverage in ASO plans

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The health benefits industry finally has something sexy to talk about: medical marijuana.

The issue is far and away the most popular topic of discussion today. But one thing that’s lacking in the general discussion is an overview of practical considerations for administrative services-only plans considering some form of coverage or wanting to prepare given the growing demand.

The answer is easier for fully insured plans. Carriers won’t support coverage today because of the lack of a drug identification number for medical marijuana and because they have no idea of how to underwrite the risk. In fairness, it would take a special kind of actuary to price the risk involved with a product that has dozens of different dosage forms and strengths, personalized dosing and an array of potential uses. In the fully insured market, coverage effectively falls to health-care spending accounts.

For sponsors of administrative services-only plans, the situation is far more interesting. They flexibility in terms of how they can deal with coverage. The following are a few practical considerations for plans looking to determine how to review medical cannabis and make informed decisions around responsible coverage.

1. Need for an evidence-based approach:

From the perspective of medical marijuana advocates, the list of possible therapeutic areas for the drug stretches from chronic pain to cancer to post-traumatic stress to glaucoma and virtually everything in between.

For plan sponsors, as it stands today, the only three areas where conclusive evidence exists for supporting the use of medical marijuana are chronic pain, chemotherapy-induced nausea and vomiting and spasticity symptoms in multiple sclerosis. That’s it. Covering anything outside of these evidence-based areas today will open plans up to an endless list of possible uses.

2. Plans need to get working on the issue immediately:

All sponsors of administrative services-only plans, even those in safety-sensitive industries, will need to develop policies and processes around coverage for members actively at work and those on disability. Health Canada estimates that by 2021, more than five million Canadians aged 15 and over will use marijuana at least once that year. The trend is only going in one direction.

Worldwide, there are more than 180 registered ongoing medical marijuana clinical trials. That means the level of evidence is only going to grow across other disease-state areas that will make it very difficult for plan sponsors to avoid the subject in the long term.

3. Need for disease state-based prior authorization:

Considering an average price per gram of $8 or $9, at an average of three grams per day, a member could potentially be consuming up to $9,855 annually in plan resources for medical marijuana, before administration fees.

Marijuana is Canada’s newest blockbuster specialty drug. The way to responsibly control utilization will be to ensure those with legitimate needs have access through robust disease state-specific prior authorization.

4. The complex relationship between marijuana ingredients:

The two most significant active ingredients in marijuana are tetrahydrocannabinol (THC) and cannabidiol (CBD). THC is responsible for the psychotropic effects and thus is the biggest contributor to the impairment potential of marijuana use in the workplace. CBD isn’t psychoactive and, therefore, has more appeal to plan sponsors in terms of ensuring safe use in the workplace.

The challenge, however, is that the interaction between THC and CBD is complex. There’s research to suggest at certain ratios of the two ingredients, there appears to be an attenuation of the effects of THC by CBD. However, at other ratios, there appears to be a potentiation of the effects of THC by CBD. The issue is one plan sponsors should consider and is one that needs to be a factor in prior authorization clinical assessments.

5. Dosage and dosage forms:

Another piece to the marijuana puzzle is that dosing remains highly individualized. It also depends on the product and dosage form a person is using. This is further evidence of the need for sophisticated, disease state-specific prior authorization in this area.

There has been some great innovation in dosage forms. Increasingly, marijuana is becoming a vapourized or ingested product. One key consideration for plan sponsors around dosage form is that edible marijuana has not been included in any formal clinical studies to date for any indications. Its use is strictly based on extensions of available studies.

In addition, THC is hydroxylated by the liver into 11-OH-THC, which is a potent psychoactive metabolite. This metabolite is found in higher concentrations when cannabis is ingested as opposed to inhaled.

6. Drug interactions:

THC is metabolized by the liver enzymes CYP2C9, 2C19 and 3A4. Prescription drugs that inhibit these liver enzymes can increase THC levels and have adverse effects. This list includes certain antidepressants, stomach acid therapies, antibiotics, antifungals and blood pressure medications.

Cannabinoids can also inhibit CYP1A1, 1A2 and 1B1 liver enzymes and affect blood levels of prescriptions medications like amitriptyline that are metabolized through these pathways. Drug interaction potential is yet another piece of evidence supporting robust, case-by-case, clinically driven prior authorization programs.

Finally, there’s a need to consider commuting to and from the workplace. Some guidelines recommend that marijuana users shouldn’t drive for three to four hours after inhalation, for six hours after ingestion and for at least eight hours if they experience a subjective high. This could give rise to one dosage form or product for the workplace and another for use elsewhere where impairment concerns may not be as significant.

Mike Sullivan (msullivan@cubichealth.ca) is president of Cubic Health, an analytics and drug plan management company based in Toronto. Follow Mike on Twitter at @cubichealth.
These are the views of the author and not necessarily those of Benefits Canada.

Transcontinental Media G.P.