Attention plan sponsors with generic substitution option: Changes to Sun Life’s reimbursement percentage on brand-name drugs for members in Quebec

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To allow for valuable cost savings, we will be changing our reimbursement percentage on certain brand-name drugs for group plans that have the generic substitution option, as of October 1, 2011. If your plan contains no generic substitution option, you and your plan members will not be affected by this change.

The background

In Quebec, patented drugs are protected by RAMQ (the Public Prescription Drug Insurance Plan) for 15 years after the date they arrive on the RAMQ formulary. This means that generic options can be available on the market before the 15 year period has expired, but RAMQ and private plans are obligated to reimburse the brand-name if a plan member wants it.

For example, a brand-name drug like Lipitor is “protected" for 15 years on the RAMQ formulary, during which time RAMQ will be obligated to reimburse the brand-name (i.e. Lipitor).

Once generic options are available, however, RAMQ does allow private plans to lower their reimbursement of the brand-name drug to the 68% minimum allowed. Once the 15 year period has expired, RAMQ will reimburse only the generic price, but private plans are still obligated to reimburse the 68% minimum of brand.

This cost-savings option will lower your drug costs

Due to a number of brand-name drugs now coming off patent, we will be reducing the coinsurance payment to the RAMQ minimum of 68% on the affected drugs (for plans that contain the generic substitution option).
Which brand-name drugs are being affected?

Currently, there are approximately 50 drugs (130 Drug Identification Numbers (DINs)) identified that will be affected by this change. Plan members can contact Sun Life’s Customer Care Centre to find out if a drug they are currently taking will be affected.

Who is affected by this change?

  • All plan sponsors with plan members residing in Quebec with the generic substitution option
  • Plan members in Quebec who continue to purchase affected brand-name drugs

How will this change affect you?

If your plan contains the generic substitution option, this change means that as of October 1, 2011, you will see savings in your drug costs because you will not be obligated to pay the plan percentage for drug reimbursement any longer (e.g. 80%). The reimbursement percentage level will be set at the RAMQ minimum of 68%.

How will this affect plan members?

Your plan members will see their reimbursement level decrease if they continue to use brand-name drugs, since they will now be reimbursed at the RAMQ minimum co-insurance of 68%.

If they switch to the generic option, however, they will experience a cost savings. We have also created a communication to explain this change to members.

Next steps

As other drugs come off patent, we will adjust our reimbursement percentage accordingly for plan sponsors with members in Quebec.

Questions?

Please contact your Sun Life Financial group benefits representative.