The advantage - November 2021

November 30, 2021

the advantage
What's new

New diabetes-related claims enhancements with more improvements coming soon

In 2018, coverage for continuous glucose monitors and flash glucose monitors (collectively referred to as glucose monitoring systems or GMS) was added to benefit plans as a Green Shield Canada (GSC) standard medical device, unless an opt-out request was received from a client. At that time, plan member reimbursement of GMS was subject to an approved authorization form, a diagnosis of type one diabetes, and a minimum requirement for blood-glucose testing frequency.

To better support plan members and their access to health care, we’ve made some changes by removing unnecessary red tape from the process (all while remaining cost neutral for plan sponsors).

  • Effective immediately, this benefit will no longer be subject to a prior
    authorization requirement.
  • Instead, we will leverage our real-time claims history data to determine if the plan member is using short-acting insulin, an insulin pump, or insulin pump supplies and therefore is insulin-dependent. If present, the GMS claim will be automatically approved if coverage is included in the benefits plan.
  • If short-acting insulin, an insulin pump, or insulin pump supplies are not on file for the previous 90 days, the plan member will be required to submit a prescription with their claim stating they are insulin-dependent.

These changes will improve the plan member experience while still ensuring these devices are approved only for those plan members who truly need them. While the coverage process will change, the reasonable and customary fees and administrative guidelines – such as frequency limitations and test-strip policies – will all remain the same.

Impact to pharmacies

To date, GMS have been managed in our adjudication system (Advantage) in a way that limited pharmacies from submitting claims electronically through their software at point of sale, even though these devices and associated supplies are primarily dispensed at a pharmacy. This means that plan members have been paying out-of-pocket and submitting their claims for reimbursement themselves. While direct claim submission has been possible by the pharmacy via our online provider portal, providerConnect®, the volume of claims received has been extremely low.

As a result, we’ve updated Advantage so pharmacies can now submit these devices and supplies through their electronic software using product identification numbers (PINs). These PINs will also provide us with an opportunity to offer better direction when it comes to these devices, supplies, and provincial plans. We shared this update with pharmacies in mid-November to ensure a smooth transition and an enhanced plan member experience.

Insulin infusion pumps

As you may know, some provinces provide grant dollars towards insulin infusion pumps. In the past, applying those grant dollars has been complicated and time-consuming for an insurer. To simplify and streamline the process, we will be moving to a standard deductible process in Q1 of 2022. Depending on the grant the plan member is accessing, the deductible will be applied quarterly or biannually for the same value as the grant.

Targeted communication will be issued to impacted plan members – sharing the good news that claim processing will be easier and explaining the overall process.

Our cost containment and claims management strategies for these quickly evolving benefits is not negatively impacted by the above enhancements. We continue to manage access and are using our system capability in a better, more efficient manner to ensure we’re not creating unnecessary barriers to care.

We are committed to improved diabetes management for both plan members and plan sponsors and are confident these enhancements will result in less cumbersome claiming processes and greater access for plan members living with diabetes.

Biosimilar transitioning – Quebec update and what it means for your plan members


On May 18, the Government of Quebec announced the province’s intention to implement a biosimilar switching policy under its public prescription drug insurance plan. The new Quebec policy is expected to generate annual savings of $100 million as of 2022, which is promised to be reinvested into the health care system and improve access to innovative drug therapies.

Under Quebec’s biosimilar switching policy, patients will transition to a biosimilar under the supervision of their treating physician by April 12, 2022. The biologic originator drugs that are being phased out are as follows:

Drug name Switch from this originator/reference biologic Switch to these available biosimilars
Adalimumab Humira® (AbbVie) Amgevita® (Amgen), Hadlima® (Organon), Hadlima PushTouch® (Organon), Hulio® (BGP Pharma), Hyrimoz® (Sandoz), Idacio® (Fresenius)
Bevacizumab Avastin® (Roche) Mvasi® (Amgen), Zirabev® (Pfizer)
Etanercept Enbrel® (Amgen) Brenzys® (Organon), Erelzi® (Sandoz), Erelzi SensoReady Pen® (Sandoz)
Filgrastim Neupogen® (Amgen) Grastofil® (Apotex), Nivestym® (Pfizer)
Infliximab Remicade® (Janssen) Avsola® (Amgen), Inflectra® (Pfizer), Renflexis® (Organon)
Insuline glargine Lantus® (Sanofi Aventis) Lantus Solostar® (Sanofi Aventis), Basaglar® (Lilly), Basaglar KwikPen® (Lilly)
Insuline lispro Humalog® (Lilly) Humalog KwikPen® (Lilly), Admelog® (Sanofi Aventis), Admelog SoloStar® (Sanofi Aventis)
Pegfilgrastim Neulasta® (Amgen) Fulphila® (BGP Pharma), Lapelga® (Apotex), Nyvepria® (Pfizer), Ziextenzo® (Sandoz)
Rituximab Rituxan® (Roche) Riximyo® (Sandoz), Ruxience® (Pfizer), Truxima® (Teva Innov)
Trastuzumab Herceptin® (Roche) Herzuma® (Teva Innov), Kanjinti® (Amgen), Ogivri® (BGP Pharma), Trazimera® (Pfizer)
Glatiramère* Copaxone® (Teva Innovation) Glatect® (Pharmascience)

Biosimilar transitioning for Quebec groups coming in May

Prior to the announcement, we were not able to offer our Biosimilar Transition Program for groups in Quebec due to regulations that require all private insurance plans to offer basic medication insurance coverage which must, at the very minimum, include the medications covered by the public plan, i.e., those appearing on the Régie de l’assurance maladie du Québec (RAMQ) “List of medications.”

Consistent with this provincial policy change, GSC is implementing biosimilar transitioning as a standard for all groups with plan members residing in Quebec effective May 1, 2022.

Biosimilar drugs cost 15 to 50 per cent less than originator drugs. Savings realized as a result of biosimilar transitioning will flow through a plan sponsor’s drug experience and any impacts to premiums will be applied at the next renewal. Similarly, we expect that cost reductions for high-cost biologic originator claims will also be reflected in the pooled experience for plans with stop-loss insurance.

Impact to plan members

We will be notifying plan members the week of January 31, 2022, that they will need to transition to a biosimilar alternative by May 1, 2022.

Letters will be mailed to plan members who are currently taking one of the above listed targeted biologic originator drugs. We will also recommend they consult with their prescriber to change their prescription to the applicable biosimilar drug and for other transitioning support.

In accordance with RAMQ criteria, exemptions will apply to:

  • Individuals who are pregnant will need to transition within 12 months after childbirth.
  • Pediatric patients must transition within 12 months after their 18th birthday.
  • Patients with chronic illnesses who have experienced failure to two or more biologic therapies used to treat the same condition.

Inkblot’s Access offering

With the pandemic nudging plan members towards “care that comes to them,” the situation calls for mental health services that are digital and available anytime, anywhere. As we shared in a recent GSC Update, we’re excited to lead the charge with fresh ideas and support plan sponsors in delivering robust, accessible mental health services to plan members (and their dependents).

Following is a recap of our Inkblot offerings, including the newest layer of our digital mental health strategy, called Access.

  • Inkblot Direct to Consumer (DTC): Part of our Digital Clinic, GSC plan members can connect directly with an Inkblot professional via video counselling and online chat/email support. Existing benefits plan reimbursement limitations apply.
  • Inkblot Employee Assistance Program (EAP): As GSC’s preferred EAP provider, Inkblot delivers the most tailored EAP experience in the marketplace, headlined by digital mental health care (including 24/7/365 crisis support) and backed by valuable additional services.
  • NEW! Inkblot Access:Access is a low-cost option for plan sponsors that provides plan members with a mental health hub for rapid counselling support, plus reduced rates to stretch their benefit maximums across more sessions.

So, where do you go from here? And how do you decide which offering is the best fit for your organization? The handy chart below captures the all-important details, helping you compare the key features:

Direct to Consumer Inkblot Access Inkblot EAP
Connecting with a counsellor Online access with support through chat or email Online access with support through chat or phone, including a 1-800 toll-free number 24/7/365 Online access with support through chat or phone, including a 1-800 toll-free number 24/7/365
Immediate crisis support? No Yes (with a Masters-level counsellor) Yes (with a Masters-level counsellor)
Payor Paid by the plan member Paid by the plan member Fully covered by the plan sponsor