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Response to Ontario Rheumatology Assocation regarding criteria for access to biologics


Release Date: 04/22/2015
Staff Reference: Stephen Frank

April 22, 2015


Dr. Jane Purvis
Past President
Ontario Rheumatology Association
12-16715 Yonge Street
Suite 244
Newmarket, ON L3X 1X4


Dear Dr. Purvis:

Thank-you for your letter of September 5, 2014 related to the issue of harmonizing criteria for accessing biologics in rheumatoid arthritis. We have had a chance to carefully review your letter and our comments are outlined below.

Feedback on minimum criteria for access to a biologic:

I am pleased to indicate that we are comfortable with the creation of a minimum standard for access to biologic drugs for adult RA patients. Our industry will generally provide access to a biologic on at least as favourable a basis as you have proposed. It is important to note, however, that while the majority of plans will meet the minimum criteria, there will always be rare situations where an employer may not want to adhere to the standard for whatever reason and we would have to implement their plan on that basis. As well, it will be critical for the provinces to also adopt this minimum standard in order for it to gain significant traction in the market as many private plans mirror their requirements off of the provincial government's standard.

With respect to the minimum criteria, we are comfortable with your suggested criteria for access to a biologic, namely that

A minimum a 12 week trial of Methotrexate plus one other disease modifying anti-rheumatic drug. Where combinations of nonbiologic DMARDs are impossible (a rare situation), 3 consecutive nonbiologic DMARDs would be acceptable.
Feedback on various administrative practices:

In your letter to us, you raise a number of what could be considered administrative practices of the industry. The administrative processes implemented by insurers are used across a wide range of disease states and benefits. It is costly and inefficient, in aggregate, to have too much customisation for particular conditions. As such, we are not in a position to commit to any across the board administrative changes with respect to how we communicate and interact with physicians who are treating RA. However, each insurer has taken away your feedback and will consider it on a go forward basis as potential changes to their administrative practices are reviewed. I would encourage you to reach out to individual insurers with any specific feedback on their particular processes if and as the need arises.

Next steps:

With respect to communicating with the various provinces, I can confirm that the CLHIA would be open to a joint communicating strategy to advocate for all provinces to adopt the proposed minimum standard. As we have discussed, for the minimum standard to have broad application across the private market in Canada, it will be important that the various provincial drug plans also adopt this minimum.
We would also request that all provincial and the Canadian RA associations prominently display the minimum criteria on their websites. This will allow private insurers to reference the criteria with plan sponsors and other stakeholders over time.

With respect to the inevitable periodic updates to the minimum standard, we agree that this should be done in close communication with private insurers. We would always want ample notice of any change as well as a solid understanding of the rationale for the change. The CLHIA will be happy to help coordinate such communication on a go forward basis as required.

I trust that this will all be acceptable to you. We appreciate your openness in working with our industry on this important matter and will look forward to hearing back from you shortly.

Sincerely,

Original signed by

Stephen Frank
Vice President, Policy Development and Health

c: Dr. Cory Baillie, President, Canadian Rheumatology Association
Dr. Carter Thorne, Past President, Canadian Rheumatology Association