5.12 Reference Drug Program
General Policy Description
The PharmaCare Reference Drug Program (RDP), established under the Drug Price Regulation, encourages cost-effective, first-line prescribing for common medical conditions by limiting reimbursement for certain drugs in designated therapeutic categories to a maximum daily amount payable.
Whereas the Low Cost Alternative Program applies to drugs that have identical active ingredients, the Reference Drug Program applies to drugs that are not identical but are part of the same therapeutic category and are used to treat the same conditions.
Drugs included in the Reference Drug Program may also be subject to the Low Cost Alternative Program.
General Reference Drug Program policies
Effective December 1, 2016, the Reference Drug Program currently applies to eight categories of drugs:
- Angiotensin-converting enzyme inhibitors (ACE inhibitors)
- Angiotensin receptor blockers (ARBs)
- Dihydropyridine calcium channel blockers (CCBs)
- HMGT-CoA reductase inhibitors (statins)
- Histamine2 receptor blockers (H2 blockers)
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Proton pump inhibitors (PPIs)
Designated reference drugs in each category are reimbursed up to the lesser of any applicable Low Cost Alternative Program price and the drug’s PharmaCare maximum price as reflected in the Maximum Pricing Policy.
For each category, one drug is designated as the reference drug comparator and is used to determine the maximum daily amount payable for non-reference drugs in the category.
The maximum daily amount payable for each category changes in relation to any change in the reference drug comparator itself or to any change in the price of the reference drug comparator, including changes resulting from Low Cost Alternative Program pricing.
PharmaCare limits reimbursement for non-reference drugs in each category to the applicable maximum daily amount payable.
PharmaCare publishes the following information online in the Low Cost Alternative (LCA) and Reference Drug Program (RDP) data files:
- Reference drugs
- Non-reference drugs
- Maximum daily amounts payable for non-reference drugs
- Reference drug comparators
- Daily therapeutic doses used to determine maximum daily amounts payable
You can also consult the list of full and partial RDP benefits.
The PharmaCare Low Cost Alternative (LCA) and Reference Drug Program (RDP) Data Files should not be considered an endorsement by PharmaCare of the interchangeability of any products identified.
The College of Pharmacists of B.C. has delegated the responsibility for determining the interchangeability of products to B.C. pharmacists.
Pharmacists are advised to consult with the prescriber to obtain the appropriate legal authority to dispense an LCA or RDP product.
If a patient’s prescription is for a non-reference drug, the pharmacy is encouraged to make the patient aware of the fully covered reference drug(s)and that the reference drug(s) provide the same or similar therapeutic treatment.
If the patient chooses the non-reference drug, they will be required to pay any amount in excess of the applicable maximum daily amount payable (and LCA price, where applicable).
PharmaCare beneficiaries taking a non-reference drug have three options:
- Switch to a reference drug
- Remain on the non-reference drug and pay any cost in excess of the amount reimbursable under the Reference Drug Program (or Low Cost Alternative Program, where applicable)
Fair PharmaCare patients should be made aware that only the lower amount (i.e., the amount reimbursable under the Reference Drug Program) will accumulate toward the family deductible, even if they choose to pay the price difference for the non-reference drug
- Have their physician request a Special Authority for full reimbursement of a non-reference drug, when individual circumstances warrant
The Special Authority process is designed to ensure access to drugs based on patient-specific needs.
If a patient has a specific medical condition that prevents them from taking the reference drug(s) in an RDP category (e.g., a drug-to-drug interaction, drug intolerance or previous treatment failure), their physician may submit a Special Authority Request for full benefit coverage of a non-reference drug.
When a Special Authority is granted, coverage will be provided up to the lesser of:
- Any applicable Low Cost Alternative price for the product, or
- The claimed drug cost or the maximum allowable price for the drug, as defined by the Maximum Pricing Policy
A Special Authority does not override plan deductibles or co-payments.
Claims for drugs subject to the Reference Drug Program can be claimed in the normal manner. PharmaNet automatically adjudicates the claim under the Reference Drug Program and any other applicable pricing program or policy.