The new exception drugsLinkedIn
There, in black and white
NB Bulletin Vol. 6 N. 8, October 2003
In response to an opinion from the Conseil du Médicament, the Ministère de la Santé et des Services Sociaux du Québec has decided to transfer the Symbicort and Advair pumps for asthmatics to Québec's drug insurance plan's list of "exception drugs", as of October 1, 2003.
The two pumps contain both cortisone and a long-acting bronchiodilator. This combination gives chronic asthmatics more effective control over the disease than quick-relief medications such as Ventolin. Due to their high cost ($75 per month for Symbicort and $121 per month for Advair), the two medications should normally be prescribed only as a second recourse. However, Conseil du Médicament statistics indicate that this is not the case.
In the months of June to September of 2003, the two pumps alone cost the provincial drug plan approximately $11 million. Therefore, adding them to the list of exception drugs should reduce the overall cost of the plan. The Ministre de la santé et des services sociaux du Québec, Dr. Philippe Couillard, said that other medications might soon be subject to the same change. It is expected that this will apply to widely used and expensive medications, such as anti-inflammatories.
Reimbursement requests for medications on the list of exception drugs must be approved by the Régie de l'Assurance Maladie du Québec (RAMQ). From now on, doctors whose patients are covered by the government plan must fill out the exception request form so that asthmatics for whom they prescribe Symbicort or Advair pumps can be reimbursed by the provincial plan. However, please note that people who are considered as being under treatment, meaning that they obtained either pump between July 18 and September 30, 2003, should receive RAMQ approval automatically, and will continue to be reimbursed.
These changes may affect your group insurance plan. A plan that applies the same criteria as the RAMQ for medications on the list of exception drugs could see fewer claims. At the same time, members who are affected by this measure might decide to obtain a prescription for either pump (or both), even if they do not meet the criteria, and therefore, would have to cover the full cost themselves.
Insurer practice varies when it comes to reimbursement for medications on the list of exception drugs. Three insurers (Great-West, SSQ, and Sun Life) and one claims manager (Claims Secure) told us that they require a form from the treating physician in order to reimburse exception drugs. Four other insurers (Standard Life, Desjardins Sécurité financière, Maritime Life, and Manulife Financial) said that they require a form from the treating physician only for plans that replicate the RAMQ plan ("RAMQ clause"), but not for more generous plans (such as "limitation clause" plans or "open clause" plans which cover some drugs and drug costs beyond provincial minimums). L'Industrielle Alliance requires a form from the treating physician, but only applies the exception drugs clause if it is added to the policy by the client. Finally, La Capitale told us that they are applying the RAMQ rules to exception drugs in most cases, but they were not able to confirm what they will do in the case of Symbicort and Advair pumps.
Please feel free to contact us for additional information.
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