BOTOX® : coverage and access in Canada
What is BOTOX®?
BOTOX® was approved by Health Canada in 2011 to treat chronic migraine and it has been available in Canada for over 30 years. It is also used to treat a number of other medical conditions including blepharospasm, strabismus, spasticity (including spasticity of the foot in children with cerebral palsy), overactive bladder, cervical dystonia, excessive sweating of the underarms, and wrinkles. 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 $714 (May 2020) plus pharmacy mark-up and dispensing fee.
Most private plans and some public plans will cover all or part of the cost of BOTOX®. Often times the prescribing physician will have to fill a form to confirm that other preventive medications have been tried without success.
Is BOTOX® covered by government drug plans?
BOTOX® for the treatment of chronic migraine is currently covered under the Alberta government drug plan and it may be covered under the Ontario and Quebec government drug plans if specific criteria are met. (For Ontario government criteria, please see this document and information on applying, please go here). For the Quebec government drug plan, a patient d’exception form must be completed and submitted. This form can be accessed here.
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:
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 1 or more migraine preventive medications
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 1 or more migraine preventive medications
Some companies will require a proof of effectiveness, like a 30% or 50% response in frequency, improvement in some quality of life scales (for example 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.
Note that BOTOX® injectors may include neurologists, pain specialists, headache specialists, anesthesiologists, family physicians, physiatrists and other medical professionals experienced in treating migraine. Some injectors might provide injections but not a global management of migraine.
My insurance company covers 80% of BOTOX® costs for migraine. Do I have to pay the rest?
Allergan, the company that makes BOTOX®, offers a co-pay program to help with the cost of treatment. Through this program, you may be eligible to receive up to 20% coverage towards the cost of each BOTOX® treatment. The program works with physical cards or digital codes depending on the pharmacy you use to fill your BOTOX® prescription, and both of which offer equal access to co-pay support. Access to the program is managed by health care providers who prescribe BOTOX®. Ask your health care provider to learn more.
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.
Alberta and Quebec have fee codes (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 physician, 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.
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.
Post#1206
