5.8 High-Cost Drugs Policy
Last updated on August 12, 2025[December 2019: Clarified policy details]
General Policy Description
Certain high-cost drugs are subject to specific reimbursement limits under the Drug Price Regulation.
Policy Details
PharmaCare reimburses drugs designated as high-cost drugs under the Drug Price Regulation up to a maximum price based on the sum of the manufacturer list price for the drug and specific percentage of that price (usually 5% or less).
PharmaCare considers the total cost of the drug per patient, which is partially dependent on the expected duration of use, when determining whether a drug should be designated a high-cost drug.
Refer to the List of designated high-cost drugs.
Procedures
When entering a claim in PharmaNet, use the correct unit of measure. Refer to the Correct Quantities list or the PharmaCare Formulary Search.