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 |
|---|---|---|---|
| New Brunswick |
Ingredient price
|
Manufacturer's list price (MLP) | The maximum amount that the New Brunswick Drug Plans will reimburse for 1 unit of a drug product in this category is the MLP specified in the MLP list. |
| New Brunswick |
Ingredient price
|
Biosimilars Initiative | Patients who use certain originator biologics must switch to a biosimilar brand to maintain coverage under the New Brunswick Drug Plans. |
| New Brunswick |
Ingredient price
|
Actual acquisition cost (AAC) | For extemporaneous preparations (compounds), the maximum amount that the New Brunswick Drug Plans will reimburse for 1 unit (e.g., tablet, capsule, millilitre, gram, etc.) is the AAC, which is the unit price of a drug to a participating provider, based on reasonable and customary purchasing practices; this is calculated by deducting from the total amount paid or payable to purchase the drug (excluding franchise fees and shipping charges) the value of any price reduction. Payments made for AACs that do not comply with this policy are subject to audit and recovery. |
| New Brunswick |
Reimbursement policy
|
n/a | If a beneficiary pays out of pocket for a drug, the claim may be submitted for reimbursement consideration if the product is an eligible benefit, is prescribed by an authorized health care provider and is purchased at a New Brunswick pharmacy. |
| Quebec |
Generic pricing policy
|
n/a | Quebec requires that generic manufacturers provide the province with the lowest price available in other provinces. |
| Quebec |
Ingredient price
|
Wholesaler markup | The drug wholesaler’s markup is payable only if the drug has actually been purchased through an accredited wholesaler. The minister allows a maximum markup of 6.5% of the guaranteed selling price. The markup is limited to a maximum of $49, under certain terms and conditions, notably for certain expensive drugs. |
| Quebec |
Ingredient price
|
Maximum allowable cost (MAC)/maximum allowable price (MAP) | The maximum payable amount for a drug, in which case the payable price may not exceed the maximum amount indicated on the formulary. |
| Quebec |
Ingredient price
|
Low-cost alternative (LCA) | The lowest unit price established for a drug product within a set of drug products for which 2 or more manufacturers have drugs appearing on the formulary (i.e., the List of Medications) that have the same generic name, dosage form and strength. Certain exceptions apply. |
| Quebec |
Ingredient price
|
Biosimilars Initiative | Reimbursement of a brand-name biologic drug is only authorized in the following cases: there is no covered biosimilar version of this drug or until 6 months after the listing of such a version to the List of Medications; a person is pregnant (including the 12 months following delivery); the request for reimbursement concerns a child or is for the remaining duration of their authorization, to a maximum of 12 months following the date of their 18th birthday; or in case of a therapeutic failure with at least 2 other biologic drugs used to treat the same medical condition. |
| Quebec |
Ingredient price
|
Actual acquisition cost (AAC) | The price indicated on the formulary that is valid at the time the prescription is filled, taking into account the source of supply and the package size. Where the manufacturer’s name does not appear on the formulary, the payable price is the pharmacist’s cost price. |