Reimbursement policies specify the allowable limits that are placed on the costs for prescription drugs. These can include policies and limitations related to ingredient pricing, the maximum cost of generic drugs, coverage of drugs with lower-cost alternatives and biosimilar switching initiatives. Each jurisdiction in Canada defines its own reimbursement policies.
| Jurisdiction | Category | Sub-category | Policy |
|---|---|---|---|
| Newfoundland and Labrador |
Generic pricing policy
|
n/a | 25%; the price policy applies to both the public and private sectors. |
| Newfoundland and Labrador |
Ingredient price
|
Low-cost alternative (LCA) | The lowest unit price of all drugs within a Newfoundland and Labrador Interchangeable Drug Products Formulary category. |
| Newfoundland and Labrador |
Ingredient price
|
Inventory adjustment fee | A percentage set by the minister that may be included in the price that may be charged for a drug listed in the formulary. |
| Newfoundland and Labrador |
Ingredient price
|
Innovator price | The price for a drug established for a single-sourced ingredient as recorded by the pharmaceutical department at the time the drug submission is received, minus 8.5%. |
| Newfoundland and Labrador |
Ingredient price
|
Defined cost | The current published manufacturer’s list price, plus 8.5%. |
| Newfoundland and Labrador |
Ingredient price
|
Biosimilars Initiative | Under this initiative, to maintain coverage, beneficiaries currently using 1 of the originator biologics of Copaxone, Enbrel, Humalog, Humira, Lantus, Lovenox, NovoRapid, Remicade and Rituxan will be transitioned to a safe, effective and less expensive biosimilar version on or before March 31, 2024. |
| Newfoundland and Labrador |
Reimbursement policy
|
n/a | Reimbursement can be considered under exceptional circumstances; out-of-province claims are considered in cases where the beneficiary is referred out of province for medical reasons and approval is obtained prior to leaving the province or if the beneficiary, while out of province for travel or non-medical purposes, experienced a medical emergency requiring hospitalization and new medications. |
| Prince Edward Island |
Generic pricing policy
|
n/a | 25%. The price policy applies to both the public and private sectors. |
| Prince Edward Island |
Ingredient price
|
Maximum allowable cost (MAC)/maximum allowable price (MAP) | The ingredient cost is based on the manufacturer’s net catalogue price of the lowest-priced product within an interchangeable category, plus 6%; when no MAP exists, the price is 10% of the ingredient cost of all brand-name drugs for which the prescription cost is $2,702 or less and 9.25% of the ingredient cost of all brand-name drugs where the prescription cost is more than $2,702. |
| Prince Edward Island |
Ingredient price
|
Biosimilars Initiative | Through the PEI Biosimilar Initiative, coverage under PEI Pharmacare for certain biologic drugs will be replaced with coverage for biosimilar drugs. |