New National Standard Established by Canadian Insurers and Rheumatologists to Provide Access to Biologic Drugs

Toronto, ON (Sept. 2, 2015) – Today, the Canadian Life and Health Insurance Association (CLHIA) and the Canadian Rheumatology Association (CRA), together with the Ontario Rheumatology Association (ORA), announced the establishment of a national standard for access to biologic drugs for adult rheumatoid arthritis patients who are members of private insurance plans. This means that, going forward, unless a plan sponsor instructs otherwise, there will be a standard set of criteria across the country that private insurers will adhere to in providing access to biologic drugs to treat rheumatoid arthritis in adult Canadians.

“One of the biggest challenges with the current system is the differing standards across Canada governing when a rheumatoid arthritis patient will have access to biologic drugs through their insurance plan,” explains Dr. Jane Purvis, Private Payer Committee Chair of the Ontario Rheumatology Association, representing the Canadian Rheumatology Association. “This new national standard will help ensure that the best clinical evidence is used to determine access and help create greater equity in access to needed biologics for Canadians regardless of where they live and who their employer is,” she added.

“Canada’s life and health insurers believe that the best way to help these patients is to have a common, clinically-based, best-practice standard for access to biologic drugs,” notes Stephen Frank, Vice-President of Policy Development and Health of the Canadian Life and Health Insurance Association (CLHIA). “This is a significant step in the right direction and our industry is committed to helping ensure that all Canadians, no matter where they live or who they work for, can access their needed drugs in a more consistent and transparent manner.”

“This new national standard is welcomed by adults living with rheumatoid arthritis,” indicates Linda Wilhelm, President of the Canadian Arthritis Patient Alliance. “It represents a transparent process for people to understand that access to biologics will be made based on clinical evidence.”

The new national standard represents a significant achievement for Canada’s prescription drug system. It also gives provincial drug plans the opportunity to adopt this standard. The CLHIA and CRA will be speaking with provincial governments on this important matter going forward.

Background Note

Canada’s life and health insurance companies, through the CLHIA, have worked closely with Canada’s leading rheumatoid arthritis clinicians to establish a national standard for access to biologic drugs for adult rheumatoid arthritis patients.

The standard was developed by a collaboration of the Canadian Rheumatology Association along with the Ontario Rheumatology Association with input from rheumatologists across the country. The new standard will be updated as needed and will be featured prominently on the CRA’s website. Going forward, Canada’s insurers will provide access to a biologic on at least as favourable a basis as set out in the standard. While the majority of plans are expected to meet the standard criteria, there may be a rare situation where a plan sponsor may choose not to follow the standard for whatever reason, and the insurer would then have to operate their plan on that basis.

The national standard will be:

  • A minimum 12 week trial of Methotrexate plus one other disease modifying anti-rheumatic drug (DMARD). Where combinations of non-biologic DMARDs are impossible (a rare situation), 3 consecutive non-biologic DMARDs would be acceptable.

About the CLHIA

Established in 1894, the CLHIA is a voluntary association whose member companies account for 99 per cent of Canada’s life and health insurance business. The industry provides a wide range of financial security products such as life insurance, annuities (including RRSPs, RRIFs and pensions) and supplementary health insurance to 28 million Canadians. It also holds more than $720 billion of assets in Canada and employs 155,000 Canadians.

Source: Canadian Life and Health Insurance Association Inc.