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 |
|---|---|---|---|
| British Columbia |
Ingredient price
|
Biosimilars Initiative | The Biosimilars Initiative was launched in May 2019 and transitions PharmaCare-covered patients taking originator drugs to equally safe and effective biosimilar versions. |
| British Columbia |
Ingredient price
|
Actual acquisition cost (AAC) | Certain products (such as blood glucose test strips or vitamin and nutritional supplements to help treat cystic fibrosis) are reimbursed at their AAC, not to exceed the manufacturer’s list price plus a 7% markup. |
| British Columbia |
Reimbursement policy
|
n/a | PharmaCare reimburses a provider any amounts payable not more than 30 days after the adjudication of a claim submitted on behalf of a beneficiary. The province does not reimburse most out-of-province claims. |
| Yukon |
Generic pricing policy
|
n/a | No generic pricing policy is currently in place; however, pharmacies order from Alberta or British Columbia wholesalers and therefore receive the prices listed in those provinces. |
| Yukon |
Ingredient price
|
Wholesaler markup | Markup added to the Drug Benefit Price; also referred to as distributor markup. Can be up to 14% for prescription medications. No wholesale markup for over-the-counter medications. |
| Yukon |
Ingredient price
|
Low-cost alternative (LCA) | Yukon Drug Program formulary benefits are based on the lowest-priced interchangeable brand available. |
| Yukon |
Ingredient price
|
Drug benefit price (DBP) | The manufacturer’s list price at which a drug or device is sold to a wholesaler or provider that does not include any wholesaler markup. This price is used for the Yukon Drug Formulary. |
| Yukon |
Ingredient price
|
Biosimilars Initiative | The Yukon Biosimilars Initiative was launched on April 3, 2023. The Initiative has already successfully transitioned 2 reference biologics to biosimilar versions. Effective October 30, 2023, the Yukon Biosimilar Initiative introduced 6 drugs listed on the Yukon Drug Plan Formulary as part of phase 2 of the Yukon Biosimilars Initiative. |
| Yukon |
Ingredient price
|
Actual acquisition cost (AAC) | The cost paid by a pharmacy to obtain a drug. This is the pharmacy’s purchase price from the manufacturer or from the wholesaler and includes the manufacturer’s drug cost and the wholesaler’s markup. |
| Yukon |
Reimbursement policy
|
n/a | When beneficiaries pay out of pocket, receipts may be submitted for reimbursement if eligible under the program. Receipts are assessed using formulary-listed prices. Exception drugs require approval; these may be backdated. Claims older than 1 year will not be reimbursed. Payment will not be made for any drug or supply receipt that is mailed from an address outside of the Yukon. |