Botox : coverage and access in Canada
What is Botox?
Botox has been used for many years for wrinkles or to treat spasticity, excessive sweating, hyperactive bladder, hemifacial hemispasm, and dystonia. Botox is a protein, a purified botulinum toxin called Onabotulinum toxin A.
To read more on Botox mechanism and effectiveness (See this post)
To read more on Botox risks and side effects (See this post)
How much does Botox cost?
The official dose of Botox used for the Chronic migraine varies between 155 and 195 units. The current cost of a Botox vial of 200 unites is $720 (January 2020). Don’t forget that the cost of any medication can be higher due to pharmacy fees.
Some insurers (private and public) will cover all or part of the cost. Most of the time the prescribing physician will have to fill a form to confirm that other preventives have been tried without success.
Is Botox covered by public drug plans?
In 2019, CADTH (https://www.cadth.ca/) changed its recommendation for the coverage of Botox by public drug insurers. Prior to 2019, the recommendation was not to cover and made access difficult in Canada for people covered by public systems. Now the recommendation is to cover if certain criteria are filled. See here for more details.
In 2019, INESSS (the equivalent of CADTH in Quebec) also made a positive recommendation to cover Botox. Since 2011, Botox was an «Patient of exception» medication and forms had to be filled by physicians. INESSS reevaluated data, including new research and safety data since 2011, and issued a recommendation for Botox to upgrade to a «Medication of exception», which should make access easier.
Overall, these two recommendations are improvements for access to Botox therapy for chronic migraine in Canada. Migraine Canada and Migraine Quebec both participated to the processes of CADTH and INESSS by submitting reports including patient input on the impact of migraine.
In BC, the Pharmacare BC institution is currently reviewing Botox. Migraine Canada also provided input for this process.
What are the criteria for my insurance to cover Botox?
Different insurance companies (public and private) have different criteria, but these are frequently seen:
- A diagnosis of Chronic Migraine
- Previous trial and failure or side effects with 2 or 3 other migraine preventives
Some companies will require a proof of effectiveness, like a 30% or 50% response in frequency, improvement in some quality of life scales (for exemple the HIT-6).
How can I find a competent injector?
Go to: mychronicmigraine.ca website.
This website provides a list of injectors that you can search by city or postal code.
Remember that Botox injectors are not necessarily neurologists or headache specialists. Some are plastic surgeons or radiologists who may be excellent to perform the injections but may not manage migraine more globally.
My insurance company covers 80% of Botox costs for migraine. Do I have to pay the rest?
The company that markets Botox, Allergan, offers a co-pay system. This means that the company would cover the costs that your insurer does not cover. This system works with cards managed by headache specialists and Botox injectors. Ask your physician about this system.
Should I pay injection fees to the physician or the clinic where I receive the injections?
This is very variable. Access to care in Canada is supposed to equitable between provinces but it is not the case for migraine care and this is one example.
Quebec has a fee code (which means that your physician is paid to perform the injections) but other provinces don’t. Physicians then have to charge fees directly to patients (which is illegal in Quebec). Fees may vary between $100 and $200. If you receive your injections from a cosmetic surgeon, fees might be higher.
Can I combine Botox and CGRP antibodies? My insurance company refuses to cover both and my physician told me I have to choose one
CGRP monoclonal antibodies (MABs) are a new class of treatment for the prevention of migraine. They can be used for Chronic but also Episodic Migraine. Read more here (See this post).
Medically, both treatments could be combined. There are reports that this combination might be effective for some people with Chronic Migraine. To read more about the Botox/CGRP MAB combination see here (LINKIN 1204).
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