Spotlight on RAMQ coverage for FreeStyle Libre

Spotlight on RAMQ coverage for FreeStyle Libre

Continuous glucose monitoring (CGM) systems offer lots of benefits, including reducing—or even eliminating—finger pricks and making it easier to prevent hypoglycemia and hyperglycemia episodes. The technology has proven to be a revolution for many, but its high cost remains a significant drawback.    

Abbott’s own CGM system, the FreeStyle Libre, is covered under the RAMQ (in Quebec) since July 2019 for people who have type 1 diabetes and meet specific criteria. 

But a lot of people are saying they still have to fork out a more or less substantial amount of money when they order it from their pharmacy. Here is some important information to help shed some light on this issue.

Criteria

The FreeStyle Libre has been approved in Canada for people aged 18 years old and over with at least 2 years’ experience in self-managing diabetes.

In order to have RAMQ coverage and receive reimbursement, you have to meet these basic criteria as well as the three following requirements:

  • Needing at least three insulin injections daily or using an insulin pump;
  • Having experienced frequent or severe hypoglycemia (episodes that result in a loss of consciousness or need another person’s intervention to be treated); 
  • Being a patient that could benefit from measuring their blood sugar at least eight times a day.

If you meet all these criteria—and most people with type 1 diabetes do—your doctor can fill out a payment authorization request for you. Generally, the request is approved for three months. After this period, your doctor must confirm that you use your system more than 70% of the time. The authorization is then renewable once a year.

Direct reimbursement at the counter

Once the reimbursement is approved by the RAMQ, you can get the reader and sensors at the pharmacy. And that’s where it gets tricky. Some people say they have to pay a large amount, and others are not paying anything. 

Why is that?

The RAMQ coverage for FreeStyle Libre sensors works the same way as the coverage for medication and capillary blood sugar test strips. You might have noticed that the amount you pay for test strips or sensors varies from one month to the next. That’s because your contribution varies—and not the cost of test strips or sensors. When you purchase drugs covered under the public plan, a portion of the cost usually comes out of your own pocket; that’s your contribution. 

Your contribution includes the following costs:

  • The monthly deductible of $21.75, which is paid with your first monthly purchases.
  • Your portion of the co-insurance, which represents 37% of the cost of covered drugs you purchase and applies once you have paid your monthly deductible and until you reach your maximum monthly contribution, if applicable.

So, the amount you pay each month can vary depending on whether you have paid your monthly deductible or not and whether you have reached your maximum monthly contribution or not. 

Here’s an example

If you are covered under the public plan, the RAMQ listed price for sensors is $89, and the pharmacist’s professional fee is set between $8 and $10 (depending on the number of drugs per year and whether it’s a new prescription or refill). If you have private insurance, the professional fee can vary significantly. If you have any doubts about the amount you have to pay, ask your pharmacist to break it down for you. 

The Freestyle Libre reader, however, must be given to you FREE OF CHARGE by your pharmacist, since the manufacturer now provides them for free.  Pharmacists who have paid for readers before this was implemented can request a refund from Abbott. You should never be charged for a reader by your pharmacy. 

In short, the FreeStyle Libre flash glucose monitoring system is now covered under the RAMQ if the eligibility criteria are met and if it’s prescribed by a doctor. The reader is provided FREE OF CHARGE by your pharmacist, and the amount you pay for sensors will vary depending on whether you have paid your monthly deductible or not and the amount you have paid for your portion of the co-insurance.  

Resources :

  • Amount to pay for prescription drugs, accessed November 6, 2019. http://www.ramq.gouv.qc.ca/en/citizens/prescription-drug-insurance/Pages/amount-to-pay-prescription-drugs.aspx
  • Rates in effect, accessed November 6, 2019. http://www.ramq.gouv.qc.ca/en/citizens/prescription-drug-insurance/Pages/rates_effect.aspx
  • Honoraires des pharmaciens : des iniquités flagrantes, à corriger au plus vite, accessed November 6, 2019. https://uniondesconsommateurs.ca/honoraires-pharmaciens/
  • Comment est déterminé le prix d’un médicament, accessed November 6, 2019. http://www.monpharmacien.ca/wp-content/uploads/2013/06/comment-prix-medicaments.pdf
  • Faits saillants de l’entente avec le MSSS, accessed November 6, 2019. https://www.aqpp.qc.ca/sites/default/files/17415_aqpp_faitssaillantsentente2018_08.pdf