Pharmacare Reimbursement List
Questions and Answers
Here are questions and answers about pharmacare benefits and reimbursement for all Nova Scotia Pharmacare programs including: Nova Scotia Seniors' Pharmacare Program, Family Pharmacare, Department of Community Services Pharmacare, Diabetes Assistance Program, and Drug Assistance for Cancer Patients.
Benefits
What benefits does Pharmacare Offer?
Pharmacare pays for drugs and supplies listed as benefits in the Nova Scotia Formulary . Drugs and supplies must be prescribed by a doctor, dentist, pharmacist, authorized optometrist, or authorized nurse practitioner. The prescription must be filled by a Nova Scotia pharmacy.
Each of our five Pharmacare programs covers different drugs and supplies. To find out if a drug or supply is covered by a particular program, use the website search option Formulary Search or call Pharmacare at 429-6565 or 1-800-544-6191.
Are generic drugs dispensed under Pharmacare?
Yes, generic drugs are dispensed under Pharmacare. Generic drugs are the same as the brand name drugs, but cost less.
Your pharmacist may choose a generic drug from a list of medicines approved as interchangeable by an expert provincial committee. These medicines may look different from the name-brand drugs, but they work the same.
If you choose the more expensive brand when you could get a generic brand, you will have to pay the difference in price between the two. If you have tried the generic brand and have had a reaction to it, ask your prescriber – your doctor or other health care provider – to report this reaction to Pharmacare. We may then pay for the more expensive brand.
What drugs and supplies are not offered under the Pharmacare Programs?
Exclusions under the Pharmacare Programs include but are not limited to:
- prescriptions filled outside Nova Scotia;
- proprietary medicines and household remedies;
- natural health products
- nonprescription analgesics, vitamins, mouth preparations, throat preparations, nasal preparations, laxatives, antacids and cough and cold preparations;
- artificial sweetening agents;
- dietary supplements and food products;
- soaps, cleaners and shampoos, medicated or otherwise;
- supportive or physical aids/devices, mechanical or otherwise;
- prescription accessories, convalescent aids or other non-drug items of a similar nature;
- cosmetic, health and beauty aids;
- blood derivatives (Immune Serum Globulin for prophylaxis against infectious hepatitis or measles for treatment of immune deficiency disease is available from Public Health);
- vaccines and sera (most are available from Public Health);
- smoking cessation therapies;
- anti-obesity therapies;
- erectile dysfunction therapies;
- infertility therapies;
- antihistamines;
- therapies for environmental illness; and
- drug products identified by trade names deemed to be inappropriate, confusing and/or misleading.
What is the Nova Scotia Formulary?
The Nova Scotia Formulary is a list of drugs and supplies that are covered under one or more of Nova Scotia's Pharmacare programs. Drugs and supplies are listed according to the Anatomical Therapeutic Chemical (ATC) Classification System. This system was developed by the World Health Organization to allow every country in the world to classify drugs in the same way. Using the ATC classification system allows us to compare our use of a drug or group of drugs with use in other countries.
Another benefit of the ATC classification system is that it groups similar drugs and supplies according to their site of action in the body. This means that when you look up a drug or supply in the Nova Scotia Formulary, you are able to see all other similar drugs or supplies. This makes it easier for prescribers to select the most appropriate product.
Next to each drug or supply listed in the Nova Scotia Formulary, there are columns to indicate:
- What is covered – The Formulary indicated whether a product is fully covered, not covered or is an exception status product.
- Which provincial drug programs cover the drug or supply (the Nova Scotia Seniors' Pharmacare Program, Family Pharmacare, Department of Community Services Pharmacare, the Nova Scotia Diabetes Assistance Program and the Drug Assistance for Cancer Patients) - Some drugs and supplies are covered under all of these plans, while others are only covered for certain plans.
- Who can prescribe the drug or supply for provincial drug programs – While many health professionals (doctors, dentists, pharmacists, nurse practitioners and optometrists) can now prescribe drugs and supplies in Nova Scotia, the provincial drug programs specify which drugs will be covered for each type of prescriber.
- Whether a Maximum Allowable Cost (MAC) applies.
- Whether a Special Maximum Allowable Cost (Special MAC) applies
Each pharmacy is provided with a subscription for a paper copy of the Nova Scotia Formulary. Updates are issued semi-annually. Any person can obtain a paper copy of the Nova Scotia Formulary in PDF format from this website. A searchable format for the Nova Scotia Formulary is also available.
Who makes the decisions regarding the benefit status of medications listed in the Nova Scotia Formulary?
The Atlantic Expert Advisory Committee and the Canadian Expert Drug Advisory Committee recommend changes to the Department of Health. These committees include medical specialists, family practitioners, and pharmacists. They consult experts in specialty areas as required.
The benefit evaluation process typically begins when a manufacturer requests to have a product evaluated for benefits status. Guidelines list the information that the manufacturer must submit. Submission requirements for the Atlantic Common Drug Review process are available on this website and submission requirements for the Canadian Common Drug Review process are available on the Canadian Agency for Drugs and Technologies in Health website. Clinical studies are reviewed extensively. Coverage for new products is not available until this process is completed and the drug has been added to the benefit list.
A drug may be added as a full benefit, denied any benefit status, or added as a benefit with criteria (referred to as exception status drugs ).
The Nova Scotia Formulary is revised regularly. Make sure you are viewing the most recent version to ensure up-to-date information.
What is an exception status drug and do you have a process to consider paying for drugs not listed as a benefit in the Nova Scotia Formulary?
Certain drugs are only eligible for coverage under the Pharmacare Programs when an individual meets criteria developed by the Atlantic and Canadian Expert Advisory Committees. These drugs are called "exception status drugs". Click here to view what drugs have exception status criteria (PDF). The request forms are available to download or from the Pharmacare office.
To request coverage, the prescriber should mail or fax the completed form or letter to the Pharmacare office. Prescribers may also contact the Pharmacare office and speak directly to a pharmacist consultant to request coverage. The prescriber must provide the following information as part of the request:
- client identification, including Nova Scotia Health Card number
- diagnosis,
- drug requested
- criteria met, and
other pertinent information.
Coverage for non-benefit drugs may also be requested in this manner for exceptional circumstances.
How long does it take to review exception status drug requests?
We try to process requests within 7 days. Urgent requests are done more quickly. Requests that do not meet defined criteria but warrant further review may take longer.
How am I notified of the decisions regarding exception status drugs?
You will be notified by a letter if the request for an exception status drug is approved. You may bring this letter to the pharmacy to verify that coverage has been approved or the pharmacist may simply bill the claim online for immediate response. The prescriber – your doctor or other health care provider - is notified if coverage is authorized, if the request does not meet the criteria, or if more information is required.
Once an exception status drug is approved, can the pharmacy bill Pharmacare for the cost of the medication?
Yes. Once approved, the exception status drug can be billed online to a Pharmacare program. Usual copay rules apply. Some exception status drugs are approved for a limited time. If you require the medication beyond the specified timeframe, your physician must re-apply for ongoing coverage. If you have received the drug while awaiting authorization and the request is eventually approved, you can usually be reimbursed. Send your receipt to the Pharmacare office. Likewise, coverage can usually be backdated up to three months to allow the pharmacy to bill waiting claims online or to reimburse you.
I understand the pharmacist can bill Pharmacare for certain exception status drugs without a request form or letter from the physician?
Yes, if the prescriber - you doctor or other health care provider - writes appropriate criteria codes on the prescription. By supplying a code, the prescriber verifies that the drug is prescribed for an indication approved under the Pharmacare programs. The prescriber may provide diagnostic information on the prescription instead of the actual code, but this information must clearly indicate to the pharmacist which code should be used. Any situation that falls outside the criteria identified by the codes requires prior approval. The prescriber must send a form or letter to the Pharmacare office.
In selected cases, the pharmacist may provide the criteria code to permit online billing. By doing so, the pharmacist is verifying that the drug is being prescribed for an indication under the Pharmacare program. Pharmacists may select an appropriate criteria code in the following cases only:
- proton pump inhibitor and/or clarithromycin only when they are used in the standard triple therapy regimens for the eradication of H. pylori.
- ophthalmic fluoroquinolones prescribed by an ophthalmologist
- Aerochamber®
These prescriptions are audited to determine that the appropriate criteria were met.
Reimbursement
How are pharmacies reimbursed for medications dispensed to Pharmacare Program beneficiaries?
The Nova Scotia Department of Health negotiates with the Pharmacy Association of Nova Scotia to determine maximum professional fees, allowable mark-ups, and definitions of cost that pharmacies can charge for prescriptions covered under the Pharmacare programs.
What drug cost does Pharmacare pay?
The Pharmacare program pays the actual acquisition cost (AAC) for drugs submitted to Pharmacare unless the drug has been assigned a Maximum Allowable Cost (MAC), a Special MAC, or is subject to the Pharmacare Allowance. The Pharmacare program also pays a small markup on the cost plus a professional fee.
What is the Maximum Allowable Cost (MAC)?
A Maximum Allowable Cost (MAC) is applied to those drugs that have multiple suppliers and have been deemed interchangeable – that is, brand name drugs and their generic equivalents.
For each interchangeable category, a maximum allowable cost per unit (e.g., tablet, capsule, milliliter, etc.) is determined by examining costs available from each manufacturer. The MAC is based on the lowest price available to the pharmacy.
Pharmacists can bill the patient extra costs above the MAC price if the patient requests a particular brand and is willing to pay the difference. This extra cost is not counted towards a Pharmacare program's deductible or maximum annual copay.
MAC prices are reviewed each January and each July. Then a new Reimbursement List (PDF)is published and sent to all pharmacies in Nova Scotia. Updates may also be provided in the interim.
Are exemptions to the Maximum Allowable Cost (MAC) considered?
Yes. Exemptions to a MAC are available for patients who have experienced side effects with lower cost alternatives. A request must be received from the prescriber detailing the reaction. Exemptions will not be considered if the brand name company makes its own identical generic. This is called an "ultrageneric" alternative.
What is a Special MAC?
For certain categories of drugs, a Special MAC (Maximum Allowable Cost) is assigned to drugs within that therapeutic category. Special MACs have been assigned to:
- Certain groups of drugs similar in therapeutic effect;
- Specific services for which coverage is established;
- Some unit dose and special delivery formats that are also available in less expensive formats; and
- Some supplies used for the same function.
The Special MAC price is the maximum amount the Pharmacare Programs reimburses pharmacies for one unit of a drug (tablet, capsule, milliliter, etc.), supply or service.
For drugs similar in therapeutic effect, a maximum daily amount the Pharmacare Programs will reimburse for any drug in that Special MAC category is established. For each strength of each drug in the category, the Special MAC is calculated as follows:
- The maximum daily dose of the drug of the drug (as published in the manufacturer's product monograph) is identified.
- The maximum daily amount the Pharmacare Programs will reimburse for the Special MAC category is divided by the number of units (tables, capsules, milliliters, etc.) required to achieve the maximum daily dose. The result, rounded down to the nearest whole number, is the Special MAC price for that strength.
For insured services, the Pharmacare programs will establish a maximum reimbursement amount for each specific service. The amount will vary according to the value of the service to the Pharmacare programs and the effort required to complete the service.
For unit dose and special delivery formats that are also available in less expensive formats, the Special MAC price is the unit price of an equal dose of the less expensive format.
For supplies used for the same function, such as lancets and blood glucose testing strips, a maximum amount the Pharmacare programs will reimburse for a unit of any product in that category is established. This is the Special MAC price and is assigned to each unit of all brands of supplies in that category.
What is the Pharmacare Allowance?
Manufactures of generic drugs provide significant rebates to pharmacies that purchase their product. These are called professional allowances. These rebates are not reflected in the list prices used by the Pharmacare programs to calculate Maximum Allowable Cost (MAC) prices. The Pharmacare program discounts certain MAC prices by an amount, referred to as the Pharmacare Allowance, to reflect a transfer of a portion of the pharmacy's rebate to the Pharmacare programs and its beneficiaries. The Pharmacare Allowance is currently 15 per cent and is applied to the top 20 (by cost) interchangeable, multi-source generic categories covered under the Pharmacare programs.
Is there a limit on the quantity of drugs that will be reimbursed by the Pharmacare Programs?
Yes. The Pharmacare Programs will reimburse pharmacies for prescriptions for up to a 100 days' supply.
Exception for Seniors Pharmacare Program beneficiaries:
Senior's Pharmacare Program beneficiaries traveling outside the province for more than 100 days will be allowed to obtain two prescriptions for the same medication before leaving Nova Scotia. Neither prescription can exceed a 90 days' supply (maximum 180 days supply for two prescriptions). The usual professional fee and copayment are to be applied to each of the prescriptions.