| Drug Plan & Extended Benefits
The Saskatchewan Drug Plan
The Drug Plan was established to:
- provide coverage to Saskatchewan residents for quality pharmaceutical products
of proven therapeutic effectiveness
- reduce the direct cost of prescription drugs to Saskatchewan residents
- reduce the cost of drug materials
- encourage the rational use of prescription drugs.
Saskatchewan residents with valid Saskatchewan Health coverage may be eligible
for Drug Plan benefits. Costs of prescriptions vary depending on the type
of benefits individuals receive.
Citizens whose health services are
covered under First Nations & Inuit Health, Health Canada, Department of Veteran
Affairs, Royal Canadian Mounted Police, Canadian Forces, Worker's Compensation
and Federal Penitentiaries are not eligible for Drug Plan benefits under Saskatchewan
Health.
Drugs Covered by the Drug Plan
With the exception of insulin, blood-testing agents, urine-testing agents,
syringes, needles, lancets and swabs for persons with diabetes, a prescription
is required for all drugs eligible for coverage under the Drug Plan.
Encouraging Appropriate Drug Use
Pharmacy Claims Processing
Pharmacy Reimbursements
Prescription Quantities
The Formulary
The Saskatchewan Formulary
is a listing of the therapeutically effective drugs of proven high quality that
have been approved for coverage under the Drug Plan. It is compiled by the Minister
of Health with the advice of the Saskatchewan Formulary Committee (SFC) and is
then prepared, maintained and distributed by the Drug Plan and Extended Benefits
Branch.
The SFC is advised and assisted by the Drug Quality Assessment Committee (DQAC).
Members of both committees are appointed by the Minister of Health.
The Saskatchewan Formulary is published annually in July. Additions to
the Formulary are made throughout the year; interchangeable generic drugs are
added monthly and other products are added quarterly.
The ongoing work of the SFC includes the evaluation of new drug products as
they are introduced, and the periodic re-evaluation of all listed products. The
goal is to list a range and variety of drugs that will enable prescribers to select
an effective course of therapy for most patients.
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The Drug Review Process
Saskatchewan is participating in the Common Drug Review (CDR). The CDR provides
participating federal, provincial and territorial drug benefit plans with a systematic
review of the available clinical evidence, a critique of manufacturer-submitted
pharmacoeconomic studies and a formulary listing recommendation made by the Canadian
Expert Drug Advisory Committee (CEDAC). For more information about the CDR and
CEDAC, visit http://www.cadth.ca/
Note: The Drug Review process described below is in transition and
will be changing to reflect the CDR process.
When a drug is introduced to the Canadian market, the manufacturer submits
a request to the Drug Plan so that it can be considered for possible coverage.
The request must be supported by scientific reports and manufacturing documents
to show that the product meets accepted standards of quality, effectiveness and
safety.
The DQAC carries out an initial evaluation of the submission, with emphasis
on clinical documents, such as reports of scientific studies comparing the new
product with existing therapeutic alternatives. In the case of new brands of currently
listed products, the DQAC ensures that the products meet accepted standards for
interchangability.
The DQAC reports its findings to the SFC. Using this information, along with
additional details of anticipated cost and impact on patterns of practice, the
SFC makes a recommendation to the Minister of Health. These recommendations reflect
the "Policy for Inclusion of Products in the Saskatchewan Formulary"
(see pages xii - xiv of the Formulary 56th Edition).
The membership on the two Committees reflects its unique but complementary
mandate. The DQAC is composed of clinical specialists in internal medicine and/or
pharmacology, clinical pharmacists and pharmacologists. The SFC is made up of
representatives of the associations or institutions related to the regulation,
education, delivery and payment of drug therapy in Saskatchewan.
Exception Drug Status
Certain drugs are approved for coverage under the Exception Drug Status (EDS)
Program, upon review and recommendation of the Saskatchewan Formulary Committee.
The drugs usually fall into one of these categories:
- The drug is ordinarily administered only to hospital in-patients but is being
administered outside of a hospital because of unusual circumstances.
- The drug is not ordinarily prescribed or administered in Saskatchewan, but
is being prescribed because it is required in the diagnosis or treatment of an
illness, disability or condition rarely found in Saskatchewan.
- The drug is infrequently used because Formulary products are usually effective,
but cannot be used or have been found to be ineffective due to the clinical condition
of the patient.
- The drug has been deleted from the Formulary but is required by patients previously
stabilized on the drug.
- The drug has potential for use in other than approved indications.
- The drug has potential for the development of widespread inappropriate use.
- The drug is more expensive than listed alternatives and offers an advantage
in only a limited number of indications.
If the EDS drug is approved as a benefit, then the patient would pay for the
EDS drug in the same manner as they would for any other benefit drug, subject
to the patient's drug coverage, as well as Department policies such as generic
interchangeability and the Maximum Allowable Cost policy.
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EDS Application Process
Prescribers and pharmacists may apply for EDS requests by telephone, mail or
fax. A toll-free line with an electronic message system is available exclusively
for requests on a 24-hour basis. The telephone number to access this line is:
1-800-667-2549; the Drug Plan fax number is (306) 787-8679.
All EDS requests must include the patient name, patient health services number
(nine digits), name of drug, diagnosis relevant to use of drug, prescriber name
and phone number. Requests are processed daily on a continuous basis.
Patients and prescribers are notified by letter if coverage has been approved
and the time period for which coverage has been approved.
If a request has been denied, letters are sent to the patient and prescriber
notifying them of the reason for the denial. In most cases, the Drug Plan requires
more information to determine the patient's eligibility for coverage and will
reconsider coverage at such time as further information is received.
If the drug requested is not a benefit under the Drug Plan, the patient and
prescriber are notified. Payment for the medication is the responsibility of the
patient in these cases. Not all medications currently available on the market
in Canada are benefits under the Saskatchewan Drug Plan or under the EDS Program
of the Drug Plan.
The majority of EDS requests are routinely backdated 30 days from the time
the Drug Plan receives the request. Provision can be made for further backdating
of EDS coverage on a case-by-case basis. However, the Drug Plan cannot backdate
further than one year from the current date.
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Over-the-counter Products
Over-the-counter (OTC) products are generally not included as benefits of the
Drug Plan.
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Product Interchangeability Pricing
Interchangeable products are different brands of the same drug
with the same strength and dosage form that are equivalent in therapeutic effectiveness
and quality.
The Formulary lists two types of interchangeable drug groups; Low Cost Alternative,
and Standing Offer Contract.
Low Cost Alternative
In order to ensure price stability for the Formulary period, the Drug Plan
and Extended Benefits Branch requires drug manufacturers to provide guaranteed
maximum prices for the period. The prices constitute the maximum price that the
Drug Plan will allow for those products during the effective Formulary period.
Any drug in a Low Cost Alternative interchangeable group can be used to fill
a prescription. The drug cost component in the approved prescription price is
the actual acquisition cost of the drug up to the lowest price listed in the Formulary
within that interchangeable group.
Standing Offer Contract (SOC)
The Drug Plan tenders high volume drugs in certain interchangeable groups to
obtain the lowest possible price. An accepted tender, called SOC, requires the
manufacturer to guarantee delivery of the specific drug to Saskatchewan pharmacies
through approved distributors at the contracted price. In return, the manufacturer's
product will be used almost exclusively. This tender process saves Saskatchewan
residents and the Drug Plan a considerable amount annually.
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Maximum Allowable Cost (MAC)
Implementation of the MAC policy began on July 1, 2004. Currently this policy
applies to one drug class, the proton pump inhibitors, and it will be expanded
to other drug classes in the future. Savings achieved with MAC will be available
to fund significant new therapies that will be coming in the future and will help
to ensure the viability of the Drug Plan.
Under the new policy, the Drug Plan obtains expert advice on which prescription
drug products within a group of similar medications are safe and beneficial, and
the most cost-effective. The price of the most cost-effective drugs are used as
a guide to set the maximum price the Drug Plan will cover for other similar drugs
used to treat the same condition. The MAC is not necessarily set at the price
of the lowest cost drug.
Physicians can continue to prescribe whichever drug they choose. This new policy
only limits the amount that is reimbursed.
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Encouraging Appropriate Drug Use
The Drug Plan uses a number of activities to encourage appropriate use of drugs:
- The use of Exception Drug Status coverage where drugs are only intended for
use under certain circumstances
- Funding support for:
- The Drug Evaluation Services and Roving Professor Program, which assists in
the drug review process, provides expert opinions on an ad hoc basis and delivers
drug information to promote the optimal use of pharmaceuticals in the province.
- The Saskatchewan
Drug Information Service provides consumer and professional drug information
services: Consumer Drug Information is a service for the public, Healthcare Professional
Drug Information is a service for pharmacists, physicians and other health care
professionals throughout Saskatchewan.
- The Triplicate Prescription Program operated by the College of Physicians
and Surgeons, a two-part written prescription to monitor the prescription of certain
drugs with the intent to reduce abuse.
- A province-wide drug utilization program managed by the Saskatoon Health District
as an educational resource to assist physicians in selecting the most appropriate
and cost-effective drug therapy for their patients. (RxFiles)
- The pharmacy claims processing system
which performs various checks on each prescription that is filled.
- The maintenance and use of the Drug Plan database for internal and external
drug studies and research.
- Use of product assurance agreements with drug manufacturers to monitor the
use of a particular drug and ensure that utilization and health outcomes occur
as stated in the manufacturers documentation.
- The Trial Prescription Program under which the pharmacist is encouraged to
dispense a seven or ten day supply for the initial prescription of certain drugs,
monitor the effect on the patient and if the outcomes are positive, dispense the
full prescription as directed by the physician. There is no additional cost to
the resident for this service.
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Pharmacy Claims Processing
An on-line computer network transmits prescription information from the pharmacy
to the central computer. It is then checked against stored data to determine whether
it can be approved for payment.
The check determines:
- if the drug is a benefit,
- if the beneficiary has health coverage and what type,
- if the quantity dispensed is within appropriate levels,
- if the number of prescriptions for the beneficiary is within limits,
- if the prescription is a duplicate or possible duplicate of another dispensed
prescription,
- if the prescriber is authorized and if the unit costs are within limits.
The results of the check and cost information is then transmitted back to the
pharmacy, detailing the consumer share and Drug Plan share.
Claims processing also includes Special Support assessment, reimbursement to
beneficiaries for prescriptions purchased out of province, selection of certain
approved claims for verification with the beneficiary, and assistance to pharmacies
and consumers via toll-free telephone lines.
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Pharmacy Reimbursements
According to the Agreement between Saskatchewan Health and pharmacy proprietors,
the prescription cost is calculated by adding the acquisition cost of the drug
material, the submitted pharmacy mark-up and a dispensing fee (up to a maximum).
The maximum dispensing fee is $8.46 (effective October 1, 2006). A maximum
pharmacy mark-up was implemented on August 23, 1999. The maximum mark-up allowance
calculated on the prescription drug cost is:
- 30 per cent for a drug cost up to $6.30,
- 15 per cent for a drug cost between $6.31 and $15.80, and
- 10 per cent for a drug cost of $15.81 to $200.00. (There is a maximum pharmacy
mark-up of $20.00 for drug cost over $200.00.)
For urine-testing agents, the pharmacy receives acquisition cost along with
the mark-up and a 50 per cent mark-up in place of the dispensing fee. For insulin,
the pharmacy receives acquisition cost plus a negotiated mark-up.
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Prescription Quantities
The Drug Plan places no limitation on the quantities of drugs that may be prescribed.
Prescribers exercise their professional judgment in determining the course and
duration of treatment for their patients. In most cases, the Drug Plan will not
pay benefits or credit deductibles for more than a three-month supply of a drug
at one time.
The pharmacist may charge one dispensing fee for each prescription for most
drugs listed in the Formulary. If a prescription is for the duration of one month
or more, the pharmacist is entitled to charge a dispensing fee for each 34-day
supply. The agreement does not prohibit the pharmacist from dispensing more than
a 34-day supply for one fee.
The agreement also contains a list of two-month and 100-day supply drugs. Prescribing
and dispensing should be in these quantities once the medical therapy of a patient
is in the maintenance stage, unless there are unusual circumstances that require
these quantities not be dispensed.
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