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 |
|---|---|---|---|
| Alberta |
Ingredient price
|
Low-cost alternative (LCA) | The lowest unit cost established for a drug product within a set of interchangeable drug products. Beneficiaries who choose higher-cost alternatives are responsible for paying the price difference. |
| Alberta |
Ingredient price
|
Fixed pricing rules | Applies to any drug product, other than a brand-name drug, that is listed or is under consideration for listing on the ADBL. Fixed-price drug products listed or under consideration for listing that are not subject to the pan-Canadian Select Molecule Price Initiative must be priced less than or equal to the LCA price of the most recently published ADBL, the price established through the pan-Canadian Generic Initiative or the price published in the February ADBL, whichever is lower. Fixed-price drug products subject to the pan-Canadian Select Molecule Price Initiative must be priced equal to the price established by the pan-Canadian Select Molecule Price Initiative. |
| Alberta |
Ingredient price
|
Biosimilars Initiative | Under the Alberta Biosimilars Initiative, adult patients who use the affected originator biologic drugs must switch to their biosimilar versions for the approved indications by a given switch date to maintain coverage of the molecule under the corresponding government-sponsored drug plan. At the end of the switching period, Alberta government drug plans cover only the biosimilar versions of specified originator biologics. |
| Alberta |
Ingredient price
|
Base price | The price per unit of a drug, a drug product or a product. This is published by the Alberta Blue Cross and is listed in its price List. The base price applies to drugs not listed on the ADBL. |
| Alberta |
Reimbursement policy
|
n/a | When beneficiaries pay out of pocket, reimbursement claims are permitted. Claims from out of province and out of country are permitted, but coverage is restricted to comparable benefits on the ADBL at the time of service. Claims must be received within 12 months of the service date. |
| British Columbia |
Generic pricing policy
|
n/a | Under the LCA Program, generic drugs are reimbursed as full benefits. PharmaCare does not cover generic drugs as partial benefits. The maximum list prices for LCA categories are as follows: 25% of the equivalent brand-name product’s list price for oral solids, 35% of the equivalent brand-name product’s list price for drugs available in other forms and 18%, or 10% of the equivalent brand-name product’s list price, for drugs subject to pan-Canadian pricing. |
| British Columbia |
Ingredient price
|
Retail price | Under the Retail Pricing Policy, certain products (such as insulin, insulin needles and syringes, insulin pump supplies and ostomy supplies) are reimbursed at the regular retail price with no dispensing fee. |
| British Columbia |
Ingredient price
|
Reference Drug Program (RDP) | The RDP limits reimbursement for certain drugs in designated therapeutic categories to a maximum daily amount payable. The RDP applies to drugs that are not identical but are part of the same therapeutic category and used to treat the same conditions. Drugs included in the RDP may also be subject to the low-cost alternative (LCA). The reference drug is fully covered. Other drugs within the category are only partially covered, up to a maximum daily cost based on the cost of the reference drug. The RDP currently applies to the following classes of drugs: angiotensin-converting enzyme inhibitors, angiotensin2 receptor blockers, calcium channel blockers, statins, H2 blockers, non-steroidal anti-inflammatory drugs and proton pump inhibitors. Designated reference drugs in each category are reimbursed up to the lesser of any applicable LCA price and the drug’s PharmaCare maximum price as reflected in the Maximum Pricing Policy. |
| British Columbia |
Ingredient price
|
Maximum allowable cost (MAC)/maximum allowable price (MAP) | Drugs are reimbursed to a maximum price based on the manufacturer’s list price, plus 8% (5% or less for drugs subject to the High-Cost Drugs Policy; 2% for oral hepatitis C medications; 0% for high-cost/expensive drugs for rare diseases. |
| British Columbia |
Ingredient price
|
Low-cost alternative (LCA) | The LCA applies to drugs that have identical active ingredients. LCA prices are set at the maximum accepted list price for generic drugs in an LCA category, plus 8% (5% or less for drugs subject to the High-Cost Drugs Policy). When the same drug is made and sold by 2 or more manufacturers, PharmaCare covers the less-expensive version — i.e., the low-cost alternative. |