Recap – what’s changing

The Régie de l'assurance maladie du Québec (RAMQ) will delist certain originator biologics from its formulary on April 13, 2022. To maintain RAMQ reimbursement, all patients covered under Quebec’s public plan and on these biologic drugs will have to switch to a biosimilar drug by that date. You can view the biologics targeted by RAMQ here.

There are certain exceptional cases where RAMQ will continue to cover the biologic. These include patients who are:

  • under age 18
  • pregnant
  • have had at least two therapeutic failures previously with biologics for the same chronic condition.

What the change means – plan members under age 65

For Quebec-based plan members under age 65, Sun Life is already the first payor; there is no coordination with the provincial plan. As such, Sun Life reimburses the plan member according to the terms of their employer’s drug plan.

Currently, if a plan covers less than 100% of a drug’s cost, the plan member pays a co-pay amount. However, Sun Life reimburses 100% of these biologic drug costs once a plan member reaches their annual RAMQ out-of-pocket maximum, as they are listed under RAMQ’s drug formulary.

With this change, after April 12, 2022, the co-pay amounts for the targeted biologic drugs will no longer count toward the annual RAMQ out-of-pocket maximum. This means some plan members will pay more out-of-pocket if they stay with their biologic drug choice. However, for plans with contractual out-of-pocket maximums equal or lower than the RAMQ maximum, there may be no additional cost.

What the change means – plan members aged 65 or older

For plan members aged 65 or older, most are currently covered by RAMQ as first payor. With these changes, Sun Life will now become the first payor for all delisted biologics. This will impact plan costs. It will also impact plan member costs if their plan has a co-pay for drug expenses. However, our analysis shows an impact on only a small number of plan members across the Sun Life block of business in Quebec. This impact will vary by plan.

Informing plan members

For affected plan members, Sun Life will send this communication directly to each plan member end of February 2022. Attending physicians are aware of this change and would have also engaged with the plan member regarding a possible switch. They can then assess if a biologic is still the right option for them. If they wish to continue their biologic treatment, they may be able to leverage other sources of funding, which could include manufacturer patient support programs.

Our approach to biosimilars remains the same

For biosimilar drug management, Sun Life takes a flexible, Client-centric approach that supports both you and your employees. We manage biosimilar drugs through several cost-containment programs. These generate significant savings and lessen your financial risks. They also ensure that plan members have choice and access to a broad range of treatments.

Questions? We’re here to help.

If you have fewer than 50 employees, please contact the Client Relations Representative Team at 1-866-606-8936.

If you have more than 50 employees, please contact your Sun Life Group Benefits representative.