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 |
|---|---|---|---|
| Quebec |
Reimbursement policy
|
n/a | If a resident is eligible for the Public Prescription Drug Insurance Plan and has paid out of pocket for the cost of purchased medications that are usually covered, an application for reimbursement can be made with the pharmacist. |
| Ontario |
Generic pricing policy
|
n/a | Generic drug prices are subject to the pan-Canadian Tiered Pricing Framework. The price policy applies to both the public and private sectors. To increase the use of safe and effective generic alternatives to brand-name products, pharmacists must dispense an off-formulary interchangeable generic product in the pharmacy’s inventory to Ontario Drug Benefit Program (ODB) recipients with an Exceptional Access Program approval from the ministry. Pharmacists will reimburse the cost of the generic product that is dispensed. The value of the generic drug, as set out in the Ontario Drug Benefit Formulary, sees the removal of the 10% limit due to changes made to ordinary commercial terms. |
| Ontario |
Ingredient price
|
Drug benefit price (DBP) | The DBP for a drug in a particular dosage form and strength reflects the amount — calculated per gram, millilitre, tablet, capsule or other appropriate unit — for which a listed drug product in that dosage form and strength is reimbursed by the ministry. Drug products are reimbursed at the listed DBP (or lowest DBP for an interchangeable category) plus a markup, plus the lesser of a pharmacy’s posted usual and customary fee or the ODB dispensing fee, minus the applicable copayment amount. |
| Ontario |
Ingredient price
|
Biosimilars Initiative | ODB recipients who are on an originator biologic will begin to transition to a Health Canada–approved biosimilar version of the drug. A transition period occurred between March 31, 2023, and December 29, 2023, to allow ODB program recipients to switch from an originator biologic to a biosimilar version in order to maintain ODB program coverage for their biologic. ODB program recipients will be required to switch to a biosimilar version before December 29, 2023, in order to maintain ODB program coverage for their biologic, unless an exception applies. |
| Ontario |
Reimbursement policy
|
n/a | Claims can be reimbursed for eligible drugs only when the prescription is written by an authorized prescriber licensed in Ontario and the drug is dispensed in Ontario. |
| Manitoba |
Generic pricing policy
|
n/a | Generic drug prices are subject to the pan-Canadian Tiered Pricing Framework; the pricing policy applies to both the public and private sectors. |
| Manitoba |
Ingredient price
|
Low-cost alternative (LCA) | Benefits are based on the lowest-priced interchangeable brand-name drug as listed in the formulary, whether or not the specified drug is prescribed with a “no sub” or “no substitution” instruction. |
| Manitoba |
Ingredient price
|
Biosimilars Initiative | A tiered biologics reimbursement policy exists; this requires new patients to use a biosimilar first. If that treatment fails, patients can try a reference biologic. Patients are required to try 2 Tier 1 products before being reimbursed for a Tier 2 product. Tier 1 biologic products have been determined to be the most cost-effective. |
| Manitoba |
Reimbursement policy
|
n/a | The original receipts for prescriptions purchased in another province or territory of Canada can be submitted to the drug plan for reimbursement, up to the lowest cost for the drug(s) listed in Manitoba. |
| Saskatchewan |
Generic pricing policy
|
n/a | Generic drugs (with certain exceptions, including pan-Canadian molecules) are priced based on the pan-Canadian Tiered Pricing Framework, as follows: new single source (i.e., only 1 manufacturer of a generic drug) — priced at 75% of the brand-name drug price if the product listing agreement or pricing agreement for brand-name drug exists in any jurisdiction; other single source — 85% for 2 generics, 50% for 3 or more generics, 25% for oral solids, and 35% for all dosage forms other than oral solids (liquids, patches, injectables, inhalers, etc.). |