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.
What benefits does Pharmacare offer?
Pharmacare pays for drugs and devices listed as benefits in the Nova Scotia Formulary, as well as for some services to which a level of coverage applies under a particular Pharmacare Program. Drugs, devices, and services must be prescribed by a doctor, dentist, pharmacist, midwife, authorized optometrist, or authorized nurse practitioner. The prescription must be filled at a pharmacy in Nova Scotia.
Each of our five Pharmacare Programs covers different drugs, devices, and services. To find out if a drug or device is covered by a particular program, search the Nova Scotia Formulary. To find out if a particular service is covered by a particular program, search the Pharmacists' Guide. You may also call Pharmacare at 496-7001 or 1-800-305-5026.
Are generic drugs dispensed under Pharmacare Programs?
Yes, generic drugs are dispensed under the Pharmacare Programs. Generic drugs are the same as the brand name drugs, but cost less.
Your pharmacist may choose a generic drug from a list of drugs approved as interchangeable by an expert provincial committee. These drugs 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 to report this reaction to the Pharmacare Programs. We may then pay for the more expensive brand.
What drugs and devices are not offered under the Pharmacare Programs?
Exclusions under the Pharmacare Programs include but are not limited to:
What is the Nova Scotia Formulary?
The Nova Scotia Formulary is a list of drugs and devices that are covered under one or more of Nova Scotia 's Pharmacare Programs. Drugs and devices 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 devices according to their site of action in the body. This means that when you look up a drug or device in the Nova Scotia Formulary, you are able to see all other similar drugs or devices. This makes it easier for prescribers to select the most appropriate product.
Next to each drug or device listed in the Nova Scotia Formulary, there are columns to indicate:
Pharmacies and the general public can access the most recent version of the Nova Scotia Formulary in PDF format on this website. Updates are issued monthly.
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 make recommendations on
the benefit status of drugs and devices to the Department of
Health and Wellness. 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 benefit 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 updated monthly. 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:
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 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 the appropriate Pharmacare Program. Usual deductible and copayment rules apply. Some exception status drugs are approved for a limited time. If you require the medication beyond the specified timeframe, your prescriber 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. Coverage can be backdated up to three months to allow the pharmacy to bill the claim online and reimburse you. Alternatively, you can send your original receipt to the Pharmacare Programs office for reimbursement.
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 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 and 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:
These prescriptions are audited to determine that the appropriate criteria were met.
How are pharmacies reimbursed for medications dispensed to Pharmacare Program beneficiaries?
The Nova Scotia Department of Health and Wellness 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 Programs pay the actual acquisition cost (AAC) or manufacturer's list price (MLP) for drugs submitted to the Pharmacare Programs, unless the drug has been assigned a Maximum Reimbursable Price (MRP) or a Pharmacare Reimbursement Price (PRP). The Pharmacare Programs also pay a markup on the cost plus a professional fee.
MRP is the maximum reimbursable price established by the Pharmacare Programs for an interchangeable generic drug. MRP is applied to those drugs which are Pharmacare benefits and have been deemed interchangeable (e.g., brand name drugs and their generic equivalents).
The MRP is the maximum amount that the Pharmacare Programs will reimburse pharmacies for one unit (tablet, capsule, millilitre, etc.) of a drug.
For each interchangeable generic drug category, a maximum reimbursable price per unit (e.g., tablet, capsule, millilitre) is determined by calculating a percentage of the cost of the equivalent brand name drug. The percentage the MRP is based on will eventually be 35%, but is phased in as follows:
Some generic drugs may have exceptions to the MRP formula, and their MRP will also be included in the Reimbursement List.
Pharmacies shall not charge any cost difference between the AAC of the drug and amount reimbursed by the Pharmacare Programs unless the beneficiary requests the higher priced drug. If the beneficiary requests the higher priced drug, the extra cost is not counted toward their annual maximum copayment or annual maximum deductible.
Are exemptions to the Maximum Reimbursable Price (MRP) considered?
Yes. Exemptions to the MRP are available for beneficiaries who have experienced side effects with lower cost alternatives. A request must be received from the prescriber detailing the reaction.
What is the Pharmacare Reimbursement Price (PRP)?
PRP is the “special” maximum price assigned to:
The PRP is the maximum amount the Pharmacare Program reimburses pharmacies for one unit of a drug (tablet, capsule, millilitre, etc.), device, or service. In the case of methadone, one unit is a milligram.
The PRP is established by the Pharmacare Programs and is published in the Reimbursement List.
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:
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Page last updated 2012-02-07.