Major changes to the MÉDIC Construction insurance plans starting January 1, 2020
Obligatory substitution of lowest-price generic and biosimilar medications
Injectable products for arthritis and lancets for diabetes
Starting January 1, 2020, upon purchase of an original prescription drug for which a generic (or biosimilar) medication exists, the reimbursement will be calculated based on the lowest-price generic (or biosimilar) medication. Note that the Régie de l’assurance maladie du Québec (RAMQ) applies the lowest-price method.
If an insured chooses to purchase an original prescription drug when a generic (or biosimilar) version exists, the difference between the price of the original medication and that of the generic (or biosimilar) medication will be excluded from the annual family ceiling of $850 and will be assumed entirely by the insured.
Impacts on the insured of purchasing an original medication versus purchasing a generic (or biosimilar) medication
|Medication||Price paid||Percentage of reimbursement*||Amount reimbursed by MÉDIC||Amount paid by the insured||Amount added to the annual family ceiling|
|Generic (or biosimilar)
|Original||$150||90%||$54 (90% of $60)||$96**||$6|
* Example for a plan with no deductible with reimbursement at 90%.
** Example for a plan with no deductible with reimbursement at 90%.
In this example, the insured will spend $90 more per month if purchasing the original medication. If the insured takes this medication each month for a full year, there will be an additional expense of $1,080 per year.
Purchase of medications for more than one month
When an insured purchase medications for several months at a time, the obligatory generic substitution may have an impact. This is because the reimbursement amount will be calculated based on the lowest price for the generic medication for all medications that must be consumed starting January 1, 2020, even if they were purchased in 2019.
Example: An insured purchases medications in December 2019 for December, January, and February.
- The medications for December 2019 will be reimbursed according to the insurance coverage for the period from July to December 2019.
- The medications for January and February 2020 must be paid in full by the insured and will be reimbursed according to the insurance coverage for the period from January to June 2020, taking account of obligatory generic substitution.
|A generic medication is produced after the patent for the original medication has expired. It contains the same active ingredients as the original medication, and its therapeutic effect is equivalent. It is therefore a “copy” of the original at a lower cost. If you are currently taking an original medication, you can ask your healthcare professional if a generic medication exists for your health problem.
A biosimilar medication is a biological medication produced after the patent for the original medication has expired. A biosimilar mediation is similar to the original biological medication, but it is much less expensive. Only your physician can determine which is appropriate for your health problem.
If, for a medical reason, an insured cannot use a generic (or biosimilar) medication, the insured must send MÉDIC Construction a copy of his or her prescription on which the prescriber has noted “do not substitute” and the reason code provided by the RAMQ. Subject to the express authorization of MÉDIC Construction, the reimbursement will then be based on the price of the original (or biological) medication.
Certain products will not be reimbursable directly in the pharmacy with the MÉDIC card. These are:
- Injectable products to relieve pain related to arthritis (e.g., Synvisc and Monovisc)
- Lancets for taking capillary blood samples in diabetes cases (not to be confused with test strips used to measure glucose levels)
However, upon medical recommendation, these products may be reimbursed. Prior authorization by MÉDIC Construction will be required. For this purpose, the form Health and professionnal care claim must be attached to the cost estimate that will be sent to MÉDIC Construction.