5.8 High-Cost Drugs Policy

[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.

Drugs designated as high-cost drugs are published on the List of Designated High-Cost Drugs.

Procedures

When entering a claim in PharmaNet, ensure that the unit of measure used for the dispensed quantity matches that used in PharmaNet. PharmaNet divides the drug cost by the dispensed quantity and compares the result to the PharmaCare pricing rules for the product. Using the correct unit of measure will ensure accurate adjudication of claims in PharmaNet.

Refer to the PharmaCare Formulary Search and the Correct Quantities list to determine the unit of measure used for a product’s PharmaCare pricing.

Tools and Resources