- Out of pocket maximum and co-insurance (starting January 1, 2021). RAMQ is increasing the out-of-pocket maximum payable for plan members residing in Quebec, for drugs listed on the RAMQ formulary. They’re also increasing the minimum co-insurance amount.
- Pharmacist-provided services (starting January 25, 2021). RAMQ is both adding and removing certain pharmacist-provided services eligible for reimbursement. It’s also increasing the amount private insurers must pay to cover these services. Reimbursements are moving from the current RAMQ minimum to 100% of the cost of the service.
Out-of-pocket maximum and co-insurance
The changes below are effective January 1, 2021.
| Legislative changes |
Drug claims for Quebec plan members |
|---|---|
Increase in annual out-of-pocket maximum to $1,144 from $1,117
|
Drug claims for plan members residing in Quebec for drugs listed on the RAMQ formulary are subject to the new annual out-of-pocket maximum of $1,144. |
| Increase in co-insurance (amount RAMQ pays) to 65% from 63% |
Drug claims for plan members residing in Quebec for drugs listed on the RAMQ formulary are subject to the new minimum co-insurance amount of 65%. |
We’ve updated our systems to reflect these changes. There will be no immediate rate adjustments due to the changes. We expect minimal impact to plan members and on claim experience.
Pharmacist-provided services
The Quebec drug insurance plan allows for the coverage of certain pharmacist-provided services. Previously, charges were reimbursed according to the plan’s co-insurance, or the minimum RAMQ reimbursement level.
As of January 25, 2021, private insurers must cover 100% of the cost of these services. Reimbursements for these services aren’t subject to any plan member co-insurances or deductibles.
Here are the services that RAMQ is adding along with the price of each.
Services added |
Fee Amount ($) |
|---|---|
Modification of drug therapy – Efficiency or safety |
20.88 |
Modification of drug therapy – Stop |
20.88 |
Therapeutic substitution of a drug – Safety |
16.88 |
Post hospitalization care service |
25.97 |
Modification of drug therapy – Other situations |
20.88 |
Therapeutic substitution of a drug – Supply disruption |
16.88 |
Assessment service for the purpose of extending a prescription and its prolongation |
13.19 |
Drug administration service to demonstrate its proper use |
19.01 |
Therapeutic substitution of a drug – Withdrawn from the market |
16.88 |
Therapeutic substitution of a drug – Problem with its administration |
16.88 |
For a list of services removed from private coverage and now fully reimbursed through the public plan, click here.
We expect these pharmacy-provided service changes to have minimal impact on your costs and those of your plan members.
Questions? We’re here to help.
For Clients with less than 50 employees, please contact your Client Service Administrator at 1-877-786-7227.
For Clients with more than 50 employees, please contact your Sun Life Group Benefits representative.
