Responding to Alberta's Biosimilar Initiative

Beginning March 15, 2021, we are changing coverage for some biologic drugs in Alberta in response to the province’s Biosimilar Initiative. These changes will help protect your clients from additional drug costs that may result from this new government policy while still providing access to equally safe and effective biosimilars.

What is Alberta’s Biosimilar Initiative?

Alberta’s Biosimilar Initiative will end provincial coverage of several originator biologic drugs for some or all conditions beginning on Jan. 15, 2021. Patients 18 and over who are using these drugs for the affected conditions will be required to switch to biosimilar versions of the drugs to maintain coverage under the province’s government drug plan.

What is the impact on private drug plans?

Industry response to Alberta’s Biosimilar Initiative has the potential to significantly impact your clients’ drug plan costs. If other insurance carriers follow suit with the province and delist the originator biologics, it could expose a plan that doesn’t delist them to significant coordination of benefits risk. (See Case Study below.)

How is Equitable Life responding?

To protect your clients’ plans from paying additional and avoidable drug costs, we are changing coverage in Alberta for most biologic drugs included in the provincial initiative.

As of March 15, 2021, several originator biologic drugs will no longer be covered for plan members of all ages in Alberta. Plan members taking these biologics will be required to switch to the biosimilar versions of these drugs to maintain eligibility under their Equitable Life plan.

What drugs and conditions are affected?

The following table outlines the drugs and conditions that will be affected by this change. The list of affected drugs or conditions is dynamic and will change as Alberta includes more biologic drugs in its Biosimilar Initiative, as new biosimilars come onto the market, and as we make changes in drug eligibility.

*Glatiramer is a non-biologic complex drug.

How will Equitable Life communicate this change to plan members?

We will be communicating with affected claimants in January 2021 to allow them ample time to change their prescriptions and avoid any interruptions in their treatment or their coverage.

Can my client maintain coverage of these biologic drugs?

Traditional groups who wish to opt out of this change and maintain coverage of these originator biologics for Alberta plan members can submit a policy amendment. Amendments must be submitted no later than January 15, 2021. Advisors with myFlex Benefits clients who wish to maintain coverage of these originator biologics for Alberta plan members should speak to their myFlex Sales Manager to confirm their eligibility to opt out of this change.

Will this change impact my clients’ rates?

The rate impact of this change in coverage will be relatively insignificant. Any cost savings associated with the change will be factored in at renewal.

If plan sponsors opt out of these changes and maintain coverage for the originator biologics, it may result in a rate increase. Any rate adjustment will be applied at renewal.

What is the difference between biologics and biosimilars?

Biologics are drugs that are engineered using living organisms like yeast and bacteria. The first version of a biologic developed is also known as the “originator” biologic. Biosimilars are also biologics. They are highly similar to the originator drug they are based on and have been shown to have no clinically meaningful differences in safety or efficacy.

Questions?

If you have any questions about this change, please contact your Group Account Executive or myFlex Sales Manager.

CASE STUDY: The Alberta Biosimilar Initiative and Coordination of Benefits (CoB) risk

CoB risk is real and can be significant, even if a pharmaceutical savings program exists.

The industry response to Alberta’s Biosimilar Initiative has the potential to significantly impact your clients’ drug plan costs. Some insurers may follow the province’s lead and delist these originator biologics. Others may cut back coverage to the cost of the biosimilars or maintain coverage of the originators. These differences could expose a plan that doesn’t delist the originator biologics to significant coordination of benefits risk. Here’s how:

Let’s assume there are two private drug plans – Plan A and Plan B. Both plans are open plans with no deductible. Plan A has 80% co-insurance and Plan B has 100% co-insurance.

BEFORE Alberta’s Biosimilar Initiative

Before Alberta’s Biosimilar Initiative, both plans cover the originator biologics listed above.

Plan A is the first private payer for an Alberta plan member taking an originator biologic drug for Rheumatoid Arthritis. Plan B is the second private payer. The cost of the originator biologic for the plan member is $30,000 annually. Here’s how the coordination of benefits would look before Alberta’s Biosimilar Initiative.

AFTER Alberta’s Biosimilar Initiative

In response to Alberta’s Biosimilar Initiative, the insurer for Plan A delists the originator biologic and requires plan members to switch to the biosimilar. The insurer for Plan B maintains coverage of the originator biologic. Under this scenario, if the plan member doesn’t switch, Plan B essentially becomes the first payer and sees their annual cost increase by 400% (from $6,000 to $30,000).

Even if the insurer for Plan B cuts back coverage to the cost of the biosimilar or adjusts the paid amount because they have a savings program in place with the drug manufacturer, the impact could be significant. For example, if the insurer cuts back coverage to 50% (or $15,000 annually), Plan B would see a 150% annual cost increase (from $6,000 to $15,000):