When will Medical Marijuana be covered by your Benefits Plan?

In 2016, there are just a handful of subjects more controversial than Medical Marijuana. When the federal government introduced rules in 2014 requiring patients to buy medical marijuana from licensed producers, it birthed an industry and drew dozens of new entrants.

While Bay Street has become the world’s leading source of financing for marijuana, Main Street has experienced a green rush of its own, with the growing number of medical marijuana dispensaries opening since Justin Trudeau’s election, leaving some Toronto City Councilors looking for ways to regulate or simply outlaw these establishments, just as the Federal Health Minister announced that Canada will table legislation a year from now to legalize Marijuana.

Ottawa has both been breaking new ground while encountering new challenges that prevent marijuana from being fully legitimized. Further, there is a question around whether or not the LCBO will be the new dispensary of choice. Given the hazy state of flux across the three branches of Government, where does this leave medical marijuana patients and their benefit plans?

Medical Marijuana Today

Cannabis is a legal treatment for patients in Canada. With a doctor’s authorization, patients can complete an application and be authorized to Possess Marijuana for Medicinal Purposes. Medical Research has shown that Cannabis products can relieve nausea, vomiting, chronic pain, while marijuana can help a person regain his or her appetite. Synthetic THC is prescribed for patients to reduce muscle spasms, while some research has shown it can be beneficial for people undergoing cancer treatment.

According to the Canadian Medical Cannabis Industry, the estimated average prescription cost is $7.50 per day, good for about one gram of medical marijuana. This is below the $12.25 dollar per day for Sativex, an opiate prescribed for patients suffering with similar conditions.

The Current State of Medical Marijuana Benefits Coverage in Canada

While the Marijuana Medical Access Regulations (MMAR) have granted access to medical marijuana to nearly 40,000 patients, many do forget that marijuana in Canada is still illegal. Marijuana’s classification as a Schedule II controlled substance makes it difficult to conduct the clinical studies. Further, cannabis doesn’t yet have a drug identification number, known as a DIN. We predict that as soon as Health Canada issues a DIN for marijuana, Canadian insurers will add some formulation to their drug benefit plans. The challenge will be how it will be adjudicated:

  • Will marijuana be allowed to be dispensed through pharmacies?
  • If marijuana has a DIN, would insurers allow direct billing from pharmacies?
  • Will newly opened ‘dispensaries’ be recognized practitioners who can bill insurers?
  • If pharmacies or dispensaries are not permitted to bill directly through a drug card, how would an insurer deal with the potential mountain of paper claims?
  • If the LCBO would be one dispensary, how would insurers develop new techniques to identify any potential for fraud, through submitting expenses for alcohol?
  • What prior authorization criteria would be considered in order to pay the claim?
  • What form of marijuana would be covered, be it through the vapour, food, or other?

While marijuana is not technically covered yet, there have been some cases in private health insurers where marijuana treatments have been covered – albeit with some pushback. The most publicized one came just over a year ago, in March 2015 when 22 year old student Jonathan Zaid got his claim paid by his insurance company. This followed a comparable decision a few years earlier a decision by the Financial Services Commission of Ontario arbitrator awarded $567.60 a month to an Ontario woman for the purchase of medical marijuana to treat pain, anxiety and insomnia symptoms. While both these cases set a precedent before the courts, it should be noted that each of these two cases are unique: both patients had suffered from rare diseases, while each had received over 40 different medications for a decade. While some benefits plans could offer medical marijuana coverage as part of a Health Care Spending Account the likelihood of this being routinely covered as a medical expense by both employers and companies is not very likely.