On February 15, 2017, Remicade, the first reference biologic drug was taken off the List of Medications covered under Quebec’s basic prescription drug insurance plan (BPDIP) for certain indications and replaced by the Inflectra biosimilar. Other reference biologic drugs will be gradually removed from the List of Medications covered under the BPDIP for certain indications. The purpose of this government initiative is to encourage the use of biosimilars.
To align with the BPDIP, La Capitale applies the same payment arrangements as the BPDIP.
Procedure for reimbursement of biologic drug expenses
To obtain reimbursement of expenses for biologic drugs requiring prior authorization, insureds must submit the Request for Assessment – Prior Authorization Drug form, duly completed by themselves and their attending physician. Following examination of the file, La Capitale will send a letter to the participant, indicating the decision made.
If the insured’s disease or medical condition corresponds to one of the indications allowing for BPDIP reimbursement of a biosimilar while a reference biologic drug has been prescribed, La Capitale confirms the denial of the reference biologic drug claim and authorization for the biosimilar. The insured must therefore get the prescription changed. The pharmacist or the attending physician can provide support in that regard.
Insureds who, following the denial of their reference biologic drug claim, decide nevertheless to receive treatment with that drug must assume all the costs of treatment.
All insureds who started receiving treatment with the reference biologic drug and obtained a reimbursement prior to the drug’s removal from the BPDIP List of Medications may continue to receive reimbursement with regard to this drug.