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PHRM 100 – PPHC > PPHC 15: Drugs – How do we pay for prescriptions? > Flashcards

PPHC 15: Drugs – How do we pay for prescriptions? Flashcards

1
Q

Health Care Rationing and Pharmacists

A
  • common example when discussing the rationing of health care resources is drug coverage
  • pharmacists deal with the consequences of health care rationing daily
  • pharmacists are in an excellent position to advocate for patients, as well as provide education to patients regarding drug coverage
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2
Q

What is a formulary?

A

comprehensive list of prescription drugs that are approved for use and covered under a particular provincial or territorial health care plan

  • each province and territory has its own formulary, and these lists can vary from one region to another
  • some drugs may be available OTC, but can be covered if prescribed
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3
Q

What are the key points about formularies in Canada?

A
  • approval for coverage
  • selection criteria
  • access to medications
  • variation across regions
  • regular updates
  • drug plans
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4
Q

BC Provincial Formulary Review Process

Stage 1 and 2

A

(federal or national)

  • federal: notice of compliance (NOC) from Health Canada’s Therapeutic Products Directorate (TPD) – permission to sell/market a drug in Canada given if drug developer gives adequate evidence of safety, efficacy, quality
  • national: common drug review by CADTH/CDA – assesses how well the drug works vs. similar drugs (value for money), and results in one of several potential outcomes (do not cover, cover if manufacturer lowers price, cover for certain patients or conditions, cover as a regular benefit)
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5
Q

BC Provincial Formulary Review Process

Stage 3

A

BC Review (Pharmacare Drug Review) – builds on the work done by Health Canada and Common Drug Review

  1. gather information and input
  • safety, clinical benefits, value for money, effect of Pharmacare coverage policies
  • input from any BC resident/caregiver with the illness/condition, BC patient advocacy groups for that condition, practicing BC clinicians with expertise in the condition, manufacturers/drug submission sponsors
  • Pharmacare budget impact
  1. review by Drug Benefit Council (DBC)
  • 12 members – 3 public, 9 experts (critical appraisal, pharmacy, ethics, health economics)
  • if the drug is first in class (new drug, new chemical, new target): requires full review of all evidence, from start to finish (efficacy, safety, cost-effectiveness) – other drugs in class may forgo a full review
  • Drug Review Resource Committee puts together evidence for DBC
  • DBC considers evidence and come to a recommendation (not a decision) – to list, to list with criteria (special authority), not to list, not to list at the submitted price (negotiation – pCPA)
  1. final decision by the Minister of Health (or deputy)
  • non-benefit: no coverage through Pharmacare
  • limited coverage: based on established criteria, pre-approval required for coverage – ie. covered for only certain patients, covered only if prescribed by certain prescribers, etc.
  • regular benefit: all beneficiaries subject to rules and deductibles
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6
Q

What is Pharmacare?

A

assistance with the cost of eligible prescription drugs, certain medical supplies, and pharmacy services

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7
Q

How is Pharmacare coverage determined?

A

income-based

  • means-based insurance plan – need to register and prove income (via tax statements), will be set a deductible (how much you pay out of pocket/need insurance for)
  • maximum you have to pay varies
  • not registered = not covered
  • family household income or individual household income – as you age out of parental coverage, you get covered individually
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8
Q

What are the 8 Pharmacare plans?

A
  • Fair PharmaCare Plan I (all British Columbians are eligible)
  • Plan B (Permanent Residents of Licensed Residential Care Facilities)
  • Plan C (Recipients of BC Income Assistance)
  • Plan D (Cystic Fibrosis)
  • Plan F (Children in the At Home Program)
  • Plan G (Psychiatric Medications)
  • Plan P (BC Palliative Care Drug Plan)
  • Plan W (First Nations Health Benefits)
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9
Q

Fair Pharmacare

What is a deductible?

A

amount a family needs to spend out of pocket each year before PharmaCare helps

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10
Q

Fair Pharmacare

How much does Pharmacare cover once the deductible is met?

A

70% – until you hit your maximum

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11
Q

Fair Pharmacare

What is a maximum?

A

the most a family will spend out of pocket each year, on eligible drugs, fees, and medical supplies

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12
Q

Fair Pharmacare

How much does Pharmacare cover once the maximum is reached?

A

100% of eligible expenses for the rest of the year

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13
Q

Fair Pharmacare

What is the threshold for regular assistance?

A

different threshold based on income

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14
Q

Fair Pharmacare

What is the threshold for enhanced assistance families?

A

(those with members born before 1940)

families earning up to $14,000 per year have no deductible or family maximum

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15
Q

What is special authority?

A

approval that allows coverage of a specific medication under certain conditions not typically met by standard criteria – grants full benefit status to a medication that would otherwise be a partial benefit or limited coverage drug

  • applications are submitted to the Ministry by the physician
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16
Q

Who/what is a special authority for?

A
  • usually for a specific drug for an individual patient
  • could be all patients of a physician/group of specialists (ie. cox2-inhibitors and rheumatologists)
17
Q

What is special authority coverage based on?

A

based on usual Pharmacare plan rules (ie. deductibles and maximums)

18
Q

Reference Drug Program (RDP)

What is this program?

A
  • medications are grouped into drug families together for coverage – active ingredients are not identical, but there is no evidence that one is significantly more effective than the others
  • one (or more) of the drugs in a family is appointed the reference drug (RD), and is fully covered under PharmaCare – rest are partially covered up to the RD price (patient or a private insurer pays the remainder)
  • prescribers can apply for Special Authority to give a non-RD drug full coverage – ie. due to drug-drug interactions, drug intolerance, or previous treatment failure
19
Q

Reference Drug Program (RDP)

What are the modernized RDP drug classes? (8)

A
  • angiotensin-converting enzyme inhibitors (ACEIs)
  • angiotensin receptor blockers (ARBs)
  • dihydropyridine calcium channel blockers (CCBs)
  • proton pump inhibitors (PPIs)
  • HMG-CoA reductase inhibitors (statins)
  • histamine-2 receptor antagonists (H2RAs)
    -non-steroidal anti-inflammatory drugs (NSAIDs)
  • nitrates
20
Q

Low Cost Alternative (LCA) Program

What is the program?

A
  • divides drugs into categories that have the same active ingredient, or combinations of active ingredients at the same strength
  • generic drugs are either benefit or non-benefit
  • PharmaCare fully covers drugs that are priced at or below the max price for their category
  • PharmaCare partially covers brand name drugs that are more expensive than the max price for their category (will cover up to the max price)
  • PharmaCare does not cover generic drugs that are more expensive than the max price for their category and are not listed in the PharmaCare formulary
21
Q

Is there any overlap between RDP and LCA programs?

A

YES – some drugs are in the LCA program and RDP at the same time

  • in this case, pharmacists usually dispense the generic version of an RDP product, according to LCA rules
22
Q

Biosimilar

What are biosimilars?

A

almost identical copies of the originator (or reference) biologic drugs

  • biologics are complex, so cannot be exactly replicated
23
Q

Biosimilar

What are 3 of the most costly drugs to plans across Canada?

A

(all biologics)

  • infliximab
  • etanercept
  • adalimumab
24
Q

Biosimilar

Who negotiates prices for biosimilars?

A

pan-Canadian Pharmaceutical Alliance

25
Q

Biosimilar

What was BC the first province to introduce?

A

mandatory switching ‘Biosimilars Initiative’

26
Q

Explain the relationship between public and private drug insurance if the patient has no private plan.

A
  • patient pays out-of-pocket until the deductible is reached
  • once deductible is reached, they pay 30% while Pharmacare pays 70% until the annual maximum
27
Q

Explain the relationship between public and private drug insurance if the patient has a private plan.

A
  • private plan pays a certain % until the deductible is reached
  • once deductible is reached, Pharmacare will pay for 70% until the annual maximum
  • remaining 30% is paid by the private plan and the patient, and the division of costs is dependent on the private plan

PHRM 100 – PPHC (18 decks)

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