Payment Methods for Prescriptions

Question 1

How are pharmacies reimbursed now?

Answer 1

Largely based on provision of pharmacy services.

Question 2

What is “dispensing”?

Answer 2

The interpretation and evaluation of a prescription, selection and manipulation or compounding of a pharmaceutical product, labelling and supply of the product in an appropriate container according to legal regulatory requirements and the provision of information and instructions by a pharmacist or under the supervision of a pharmacist, to ensure the safe and effective use by the patient.

Question 3

What is “patient-focused care”?

Answer 3

The merging of several models of health care practice including patient education, self-care and evidence based care into 4 broad areas of intervention: communication with patients, partnership with patients, health promotions and delivery of care.

Question 4

How are prescriptions paid for in Canada?

Answer 4

A mix of public and private coverage.

Question 5

What are the two types of public coverage?

Answer 5

Federal Plans: for veterans, first nationa, inuit, military personnel, recent immigrants, inmates, RCMP
Provincial Plants: for low-income seniors, recipients of social assistance, and some provinces do universal soverage.

Question 6

Which province is modelling universal coverage for its residents?

Answer 6

Quebec

Question 7

What is Third Party Billing?

Answer 7

The financial coverage for medications or pharmaceutical aids involving a contractual agreement between a third party payer and the pharmacy.

Question 8

What is a formulary?

Answer 8

A list of medications approved by the insurance company as an eligible benefit.

Question 9

What is a copay?

Answer 9

The portion of the prescription price that the patient pays (may include a percentage or cost of the prescription above what the plan pays).

Question 10

What is a deductible?

Answer 10

The amount the patient pays every year before the insurance company starts paying its share of the costs.

Question 11

What is the out-of-pocket limits?

Answer 11

The most cost-sharing a patient will ever have to pay in a year. It is the total of deductible, copays and coinsurance.

Question 12

What are types of insurance plans?

Answer 12

Government sponsored: provincially administered by Alberta Blue Cross and Federally sponsored plans
Private Plans: plans offered by employers and adjudicated by insurance carriers like Sunlife

Question 13

What is Alberta Pharmacy Fee Reibursement?

Answer 13

An agreement between the RxA, Alberta Blue Cross and the Alberta government was implemented. This includes four years of predictable funding, changes to dispensing fees and an updated pharmacy services framework that compensates pharmacists for the services they provide.

Question 14

What is the Manufacturer List Price?

Answer 14

The price of a drug listed in the ADBL.

Question 15

What is the base price?

Answer 15

The base price if the price per unit of a drug, a drug product or product. Price established by Alberta Blue Cross… Applied to drugs not listed in the ADBL

Question 16

What is the one dispensing fee introduced by Pharmacy Free Reimbursement?

Answer 16

12.30

Question 17

How did pharmacies used to be reimbursed?

Answer 17

By what products they sold and were dispensed - reimbursement was product focused.

Question 18

What is Alberta Health?

Answer 18

A ministry within the Government of Alberta which sets strategic health care policy and funds health care services.

Question 19

What organization in Alberta administers front-line health care services?

Answer 19

Alberta Health Services

Question 20

What is covered by the Alberta Health Care Insurance Plan?

Answer 20

Hospitalization, medically necessary surgery, physician vists, laboratory services, health aspects of long-term care, home care and ambulatory care services. Prescription drug services.

Question 21

What are options for paying for prescription drugs?

Answer 21

Employer sponsored health benefit plans
Individual health benefit plans
Pay out of pocket
Government sponsored coverage

Question 22

What are the differences between public and private prescription drug insurers?

Answer 22

Public drug plans have drug benefits informed by a National common drug review undergoing evidence based review. Public plans are funded partially by those using the insurance plans and then taxpayers covering the shortfall.

Question 23

Who administers Government of Alberta sponsored drug plans?

Answer 23

Alberta Blue Cross: processes claims, provides admin and research support to come on benefits list and administers special authorization process.

Question 24

What is the Alberta Drug Benefit List?

Answer 24

A mast list of benefits under the plans. It is a list of drug products converted under the plans, criteria and prices… over 4700 DINS. Both brand version and it generic alternatives. It is updated monthly.

Question 25

What are the principles underlying benefit coverage?

Answer 25

Equitable/consistent
Fair/transparent
Timely
Evidence Based
Appropriate and necessary
Sustained value

Question 26

Who is involved in adding brand drugs to the ADBL?

Answer 26

Drug manufacturers
Health Canada - NOC
Canadian Agency for Drugs and Technologies in Health
Common Drug Review
Alberta Expert Committee on Drug Evaluation and Therapeutics
Alberta Blue Cross
Alberta Health

Question 27

How does a drug get on the ADBL?

Answer 27

The drug manufacturer makes a submission, and reviews are done against submission criteria, goes through the CDR and the ABC does research to check of the drug has an NOC and if it is identified for review. Expert committees review based on therapeutic value and cost effectiveness. Alberta Health applies price policy and if drug meets the threshol. AH and Minister make final decision.