Certain products may be granted EDS
for non-approved indications. This is the case only when the Saskatchewan
Formulary Committee has reviewed evidence to demonstrate safety and efficacy
and the prescriber is aware the drug is being prescribed for a non-approved
indication.
|
* For pharmacist-initiated EDS requests:
The diagnosis, which must be obtained from the
physician or physician's agent, is to be consistently documented within
the pharmacy, whether the documentation is on the original prescription,
computer file, or EDS fax form. |
CRITERIA FOR COVERAGE UNDER EDS
The criteria is established by the
Saskatchewan Formulary Committee in consultation with the Drug Quality
Assessment Committee, and is listed in the Saskatchewan Formulary.
See Appendix A, for details regarding EDS criteria.
OVER-THE-COUNTER PRODUCTS
Over-the-counter (OTC) products are
generally not included as benefits of the Drug Plan.
Product
Interchangeability and Pricing
One function of the Saskatchewan
Formulary Committee is to identify interchangeable drug groups.
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 the 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 pharmacies through approved distributors at the
contracted price. In return, the manufacturer's product will be used almost
exclusively. This tender process, in 2007-08 saved Saskatchewan residents and
the Drug Plan approximately $12.9M.
Only the accepted tendered drug can be
used to fill a prescription in an SOC interchangeable group. If a prescription
is ordered as "no substitution" for any brand other than the SOC brand listed,
the Drug Plan will cover the actual acquisition cost up to the listed SOC unit
price. The difference in acquisition cost between the brand dispensed and the
cost covered by the Drug Plan is the responsibility of the consumer.
"No Substitution"
Prescription Drug Coverage
It is recognized that extremely rare
cases may exist in which a person is not able to use a particular brand of
product. In such cases, the physician may request exemption from full payment
of incremental cost when a specific brand of drug in an interchangeable
category is found to be essential for a particular patient. There is no
provision for "blanket" exemptions. Each request must be patient and product
specific.
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 may 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.
See Appendix I for more information regarding
MAC.
Product Distribution
Two distribution networks are used to
deliver drugs to pharmacies; manufacturers direct to pharmacies, or
manufacturers to pharmacies via distributors and Saskatchewan wholesalers.
Drug Plan
Overview
ELIGIBLE BENEFICIARIES
Saskatchewan residents with valid Saskatchewan Health Coverage may be
eligible for Drug Plan benefits.
TYPES OF BENEFICIARIES
Saskatchewan Assistance Plan recipients;
Families/Individuals applying for and approved for
Special Support;
Guaranteed Income Supplement recipients;
Persons 65 years and older who reside in licensed special
care homes or hospitals and whose income is at or below the Saskatchewan
Income Plan level;
Saskatchewan Income Plan recipients living in the
community;
Families/Individuals approved for Family Health Benefits;
SAIL beneficiaries (Paraplegics, Cystic Fibrosis, and
Chronic Renal Disease);
Persons
approved under the Drug Plan as Palliative Care;
Government Wards;
Inmates of
provincial correctional institutions;
Families granted Emergency Assistance.
Seniors' Drug Plan & Children's Drug Plan Beneficiaries (see program
information - above)
NOT ELIGIBLE
