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 |
|---|---|---|---|
| Saskatchewan |
Ingredient price
|
Maximum allowable cost (MAC)/maximum allowable price (MAP) | This is the maximum price that the drug plan covers for similar drugs used to treat the same condition. |
| Saskatchewan |
Ingredient price
|
Low-cost alternative (LCA) | Benefits are based on the lowest-priced interchangeable brand-name drug, as listed in the formulary. |
| Saskatchewan |
Ingredient price
|
Biosimilars Initiative | Under the Saskatchewan Biosimilars Initiative, patients already using a reference biologic (or “originator” biologic) with an available biosimilar version need to start using a biosimilar version of their medication to keep their coverage under the Saskatchewan Drug Plan. |
| Saskatchewan |
Ingredient price
|
Actual acquisition cost (AAC) | The ingredient cost, unless otherwise determined (i.e., LCA, MAC), is based on the actual cost of the material of a drug product, including any discounts received toward a product purchased. |
| Saskatchewan |
Reimbursement policy
|
n/a | Beneficiaries can submit claims if they have had to pay out of pocket for various reasons (system down, exception drug status coverage not in place at time of dispensing, etc.). Beneficiaries who are temporarily out of province are eligible for drug benefits, in accordance with their coverage level and Saskatchewan drug prices, upon submission of original receipts to the drug plan. |
| Alberta |
Generic pricing policy
|
n/a | Generic drugs are priced based on the pan-Canadian Tiered Pricing Framework, with the tiers set as follows: Tier 1 is priced at 75% of the brand-name drug price if the PLA or pricing agreement for the brand-name drug exists in any jurisdiction; if there is no PLA or pricing agreement, it is priced at 85% of the brand-name drug price. Tier 2 is priced at 50%. Tier 3 is priced at 25% for oral solids and 35% for all dosage forms other than oral solids (liquids, patches, injectable, inhalers, etc.). |
| Alberta |
Ingredient price
|
Transitional period price policy | The minister may establish a transitional period of up to 30 days to provide for a temporary benefit or payment for a drug product under defined circumstances; this time period may include but is not limited to the listing of a new interchangeable drug that results in the establishment of a new interchangeable grouping; or the discontinuation or removal of a drug product from the Alberta Drug Benefit List (ADBL). |
| Alberta |
Ingredient price
|
Non-fixed pricing rules | Non-fixed pricing rules: the confirmed price for a brand-name drug or other drug must be the lowest of the price less than or equal to the previous price of that drug product listed on the February ADBL, or the previous price of the drug product listed on the February ADBL, plus an increase that is less than or equal to the current Patented Medicine Prices Review Board Guidelines, which are used to determine acceptable price increases, up to a maximum of 5%. |
| Alberta |
Ingredient price
|
Maximum allowable cost (MAC)/maximum allowable price (MAP) | The maximum unit cost that Alberta’s supplementary health plans pay for a specific drug product within a grouping of therapeutically equivalent drug products and subject to MAC pricing. |
| Alberta |
Ingredient price
|
Manufacturer's list price (MLP) | The maximum unit cost established for a drug product within a specific grouping of drugs used to treat a common condition Beneficiaries who choose higher-cost alternatives are responsible for paying the price difference. |