As outlined in the December 2020 issue of The Advantage, Green Shield Canada (GSC) is launching a new pharmacogenetics benefit effective March 1, 2021. This coverage – consisting of a test and access to accompanying software provided by our partner GenXys – will be added to all extended health services plans (excluding Quebec plan members) that cover the “Diagnostic Services/Laboratory Tests (non optometric)” category, which is covered by the vast majority of our plans.
GSC’s pharmacogenetics benefit in detail
Under this coverage, eligible plan members will have access to the GenXys TreatGxplus product which includes the myPGx pharmacogenetic test and access to TreatGx medication decision-support software via computer, tablet, or mobile device. (The health care provider requesting the test also gets access to the TreatGx software.) TreatGx includes more than 40 evidence-based treatment algorithms for conditions commonly treated in primary care and provides personalized and optimized medication options by integrating an individual’s pharmacogenetic data and health information with the best clinical evidence and guidelines available. See https://www.genxys.com/content/conditions-and-medications/ for a full list of conditions and medications included in the software.
Initially the focus will be on mental health, specifically depression and anxiety, where there’s clearly a need with the rapid increase in mental health issues during the ongoing COVID-19 pandemic. However, we will evaluate other medical conditions in the future and will expand criteria where the evidence supports doing so. In all cases, eligibility will be limited to those who meet GSC’s medical criteria, therefore, prior authorization will be required.
Note that this coverage is for GenXys TreatGxplus pharmacogenetic product only, and all other pharmacogenetic tests available in the market will continue to be excluded from the benefit.
The decision to partner with GenXys was made after careful examination of the pharmacogenetic market. GenXys stood out as a provider that understands how to ensure that pharmacogenetic test results translate into actionable information that a prescriber can easily incorporate into the clinical-decision making process. This understanding is evident in their TreatGxplus offering, which includes the test, the software, and a seamless digital experience.
Meet our partner…
GSC is excited to collaborate with GenXys in providing this pharmacogenetics benefit. With industry-leading software to support prescribers and pharmacists, GenXys is a forward-thinking partner that shares our commitment to solving complex health challenges. Visit genxys.com to learn more.
A seamless plan member experience
Plan members with depression and/or anxiety who have tried and failed, or are intolerant to, at least one medication for managing their condition will be eligible for pharmacogenetic testing; their pharmacist or prescriber will simply submit a completed prior authorization form to GSC.
If approved for the test, plan members are notified by GSC and receive a link to the GenXys website along with a code. They must validate their coverage on the GenXys website and follow a short set of instructions to complete their registration and order the myPGx test kit. Plan members will also be given an option to provide consent and automatically provide their drug claim history from GSC’s system to enable personalized medication treatment options.
Once they receive the test, the plan member performs a swab of the lower gums, and sends that sample back to GenXys. When the test results are ready, both the plan member and the pharmacist or prescriber are notified that the results are available on TreatGx, so they can meet to review the report together and determine next steps.
To ensure there are no barriers for plan members accessing this benefit, the entire cost of the test ($499 plus applicable GST or HST) is covered by the benefits plan, with no co-payments or deductibles applying, subject only to an overall health maximum (if one is in place), and limited to one test per plan member per lifetime. All claims will be submitted by GenXys directly to GSC via providerConnect®, and payment will be issued directly to them.
Why is GSC’s pharmacogenetics benefit unique in the industry?
- Added as a standard benefit to our plans without a co-payment or deductible
- Subject only to an overall health maximum
- Provides a seamless and integrated digital plan member experience
- Allows plan members to work with either their doctor or pharmacist to access the test
A focus on depression and anxiety
Depression and anxiety are among the most common types of mental disorders – often experienced simultaneously – and have a major impact on all aspects of life, including employment, social functioning, and physical well-being. In Canada, an estimated 11.6 per cent of adults reported they had a mood and/or anxiety disorder with nearly one-third of them reporting this had affected their life “quite a bit” or “extremely” in the past 12 months.1 Not only do these disorders impact a person’s mental and physical well-being, but they also impose a burden on the economy. This can be measured by both increased direct (use of health care resources) and indirect (work absenteeism and presenteeism) costs. In fact, an estimated 50 per cent of costs were attributed to the workplace.2
While antidepressant medications are an effective first-line treatment for depression and/or anxiety, some individuals do not achieve symptom relief even after trying several types. Health care providers generally consider “treatment resistant depression” (TRD) to be when a patient fails to improve after a minimum of two therapies (of adequate dose and duration).3 In Canada, approximately one in five individuals diagnosed with depression experience TRD.4 These patients tend to have longer episodes of depression, are more likely to receive multiple medications, and report more side-effects from medications.4 TRD patients also experience twice as much work loss (paid disability and medical-related absenteeism)5 and nearly one-in-five end up on long-term disability.4
These findings show the need for more precise delivery of medication to optimize treatment response and improve patient outcomes sooner. The longer it takes a plan member to find the right medication, the more likely they will increase the economic burden for plan sponsors and eventually claim disability benefits. Pharmacogenetic testing has an important role to play in benefit plans when added appropriately with the ultimate goal of optimizing drug therapy and improving patient health.
Learn about our pharmacogenetics clinical trial…
This past summer, GSC released the results of our groundbreaking pharmacogenetics clinical trial study which confirmed the value of tailoring drug treatment to a person’s genetic makeup. This single-blinded randomized controlled study followed more than 200 outpatients who had been diagnosed with major mental health conditions, including depression and anxiety. You can read all about it in the summer 2020 issue of Follow the Script®.
Impact to your plan
Cost impacts will flow through your extended health services experience and any changes will be applied at renewal. Over our entire book of business, we estimate that the impact will be less than one per cent of total health costs; however, a number of factors could impact the degree of uptake related to this change, most visibly the prevalence of depression and anxiety in the employee population. The cost impact reflects the estimated uptake which is based on the prevalence of depression and anxiety medication use across our book, and the number of individuals that would meet the established medical criteria.
Next steps
Effective March 1, 2021, pharmacogenetics coverage will be automatically added to all GSC benefit plans that cover the “Diagnostic Services/Laboratory Tests (non optometric)” category. As shared in mid-December, if you do not want this coverage included in your plan, be sure to advise your account team by January 29, 2021.
Coverage for Quebec plan members is expected to be available at a later time in 2021; additional details will be shared once available.
Sources:
1 Mood and Anxiety Disorders in Canada. “Fast facts from the 2014 Survey on Living with Chronic Diseases in Canada.” Government of Canada. Available at: https://www.canada.ca/en/public-health/services/publications/diseases-conditions/mood-anxiety-disorders-canada.html.
2 Greenberg PE, Fournier AA, Sisitsky T, Pike CT, Kessler RC. “The economic burden of adults with major depressive disorder in the United States (2005 and 2010).” J Clin Psychiatry. 2015; 76(2): 155-162. doi:10.4088/JCP.14m09298.
3 Gaynes BN, Lux L, Gartlehner G, et al. “Defining treatment-resistant depression.” Depress Anxiety. 2020; 37(2): 134-145. doi:10.1002/da.22968.
4 Rizvi SJ, Grima E, Tan M, et al. “Treatment-Resistant Depression in Primary Care across Canada.” The Canadian Journal of Psychiatry. 2014; 59(7): 349-357. doi:10.1177/070674371405900702.
5 Zhdanava M, Kuvadia H, Joshi K, et al. “Economic Burden of Treatment-Resistant Depression in Privately Insured U.S. Patients with Physical Conditions.” Journal of Managed Care & Specialty Pharmacy. 2020; 26(8): 996-1007.
