Benefits and Reimbursement

Nova Scotia Pharmacare

Benefits and Reimbursement

Below are some common questions and answers about program benefits and reimbursement for all Nova Scotia Pharmacare Programs.

Benefits Questions and Answers

What benefits does Pharmacare offer?

Pharmacare helps residents with the cost of prescribed drugs and devices listed as benefits in the Nova Scotia Formulary, as well as with the cost for some services to which a level of coverage applies under a particular Pharmacare Program. Drugs and devices must be prescribed by a doctor, dentist, pharmacist, midwife, authorized optometrist, or authorized nurse practitioner. The prescription must be filled at a pharmacy in Nova Scotia.

Each of our Pharmacare Programs covers different drugs, devices, and services. To find out if a drug or device is covered by a particular program, search the Nova Scotia Formulary. To find out if a particular service is covered by a particular program, search the Pharmacists' Guide. You may also call Pharmacare at 902-429-6565 or 1-800-544-6191.

Are generic drugs dispensed under Pharmacare Programs?

Yes, generic drugs are dispensed under the Pharmacare Programs. Generic drugs are the same as the brand name drugs, but cost less.

Your pharmacist may choose a generic drug from a list of drugs approved as interchangeable by an expert provincial committee. These drugs may look different from the name-brand drugs, but they work the same.

If you choose the more expensive brand when you could get a generic brand, you will have to pay the difference in price between the two. If you have tried the generic brand and have had a reaction to it, ask your prescriber to report this reaction to the Pharmacare Programs. We may then pay for the more expensive brand.

What drugs and devices are not offered under the Pharmacare Programs?

Exclusions under the Pharmacare Programs include but are not limited to:

  • proprietary medicines and household remedies;
  • non-prescription analgesics, antihistamines, vitamins, natural health products, mouth preparations, throat preparations, nasal preparations, laxatives, antacids, and cough and cold preparations;
  • artificial sweetening agents;
  • dietary supplements and food products;
  • soaps, cleansers, and shampoos, medicated or otherwise;
  • supportive or physical aids/devices, mechanical or otherwise;
  • prescription accessories, convalescent aids or other non-drug items of a similar nature;
  • cosmetic, health and beauty aids;
  • blood  derivatives  (Immune  Serum  Globulin  for  prophylaxis  against  infectious  hepatitis  or measles for treatment of immune deficiency disease available from Public Health);
  • vaccines and sera (most are available from Public Health);
  • anti-obesity therapies;
  • erectile dysfunction therapies;
  • infertility therapies;
  • therapies for environmental illness;
  • drug products identified by trade names deemed to be inappropriate, confusing, and/or misleading;
  • wound care products.

What is the Nova Scotia Formulary?

The Nova Scotia Formulary is a list of drugs and devices that are covered under one or more of Nova Scotia’s Pharmacare Programs. Drugs and devices are listed according to the Anatomical Therapeutic Chemical (ATC) Classification System. This system was developed by the World Health Organization to allow every country in the world to classify drugs in the same way. Using the ATC classification system allows us to compare our use of a drug or group of drugs with use in other countries.

Another benefit of the ATC classification system is that it groups similar drugs and devices according to their site of action in the body. This means that when you look up a drug or device in the Formulary, you are able to see all other similar drugs or devices. This makes it easier for prescribers to select the most appropriate product.
Next to each drug or device listed in the Formulary, there are columns to indicate:

  • What is covered – The Formulary indicates whether a product is fully covered, not covered, or is an exception status product.
  • Which provincial drug programs cover the drug or device (the Nova Scotia Seniors' Pharmacare Program, Family Pharmacare, Department of Community Services Pharmacare, the Nova Scotia Diabetes Assistance Program and the Drug Assistance for Cancer Patients) – Some drugs and devices are covered under all of these plans, while others are only covered for certain plans.
  • Who can prescribe the drug or device for the Pharmacare Programs – While many health professionals (doctors, dentists, pharmacists, nurse practitioners and optometrists) can now prescribe drugs and devices in Nova Scotia, the provincial drug programs specify which will be covered for each type of prescriber.

Pharmacies and the general public can access the most recent version of the Formulary in PDF format on this website. Updates are issued monthly.

Who makes the decisions regarding the benefit status of medications listed in the Nova Scotia Formulary?

The Atlantic Expert Advisory Committee and the Canadian Expert Drug Advisory Committee make recommendations on the benefit status of drugs and devices to the Department of Health and Wellness. These committees include medical specialists, family practitioners, and pharmacists. They consult experts in specialty areas as required.

The benefit evaluation process typically begins when a manufacturer requests to have a product evaluated for benefit status. Guidelines list the information that the manufacturer must submit. Submission requirements for the Atlantic Common Drug Review process are available on this website and submission requirements for the Canadian Common Drug Review process are available on the Canadian Agency for Drugs and Technologies in Health website. Clinical studies are reviewed extensively. Coverage for new products is not available until this process is completed and the drug has been added to the benefit list.

A drug may be added as a full benefit, denied any benefit status, or added as a benefit with criteria (referred to as exception status drugs).

The Nova Scotia Formulary is updated monthly. Make sure you are viewing the most recent version to ensure up-to-date information.

What is an exception status drug and do you have a process to consider paying for drugs not listed as a benefit in the Nova Scotia Formulary?

Certain drugs are only eligible for coverage under the Pharmacare Programs when an individual meets criteria developed by the Atlantic and Canadian Expert Advisory Committees. These drugs are called "exception status drugs". To view what drugs have exception status criteria or to download request forms, see Exception Status Drugs.

To request coverage, the prescriber should mail or fax the completed form or letter to the Pharmacare office. Prescribers may also contact the Pharmacare office and speak directly to a pharmacist consultant to request coverage. The prescriber must provide the following information as part of the request:

  • client identification, including Nova Scotia Health Card number;
  • diagnosis;
  • drug requested;
  • criteria met; and
  • other pertinent information.

Coverage for non-benefit drugs may also be requested in this manner for exceptional circumstances.

How long does it take to review exception status drug requests?

We try to process requests within 7 days. Urgent requests are done more quickly. Requests that do not meet defined criteria but warrant further review may take longer.

How am I notified of the decisions regarding exception status drugs?

You will be notified by a letter if the request for an exception status drug is approved. You may bring this letter to the pharmacy to verify that coverage has been approved or the pharmacist may simply bill the claim online for immediate response. The prescriber is notified if coverage is authorized, if the request does not meet the criteria, or if more information is required.

Once an exception status drug is approved, can the pharmacy bill Pharmacare for the cost of the medication?

Yes. Once approved, the exception status drug can be billed online to the appropriate Pharmacare Program. Usual deductible and copayment rules apply. Some exception status drugs are approved for a limited time. If you require the medication beyond the specified timeframe, your prescriber must re-apply for ongoing coverage. If you have received the drug while awaiting authorization and the request is eventually approved, you can usually be reimbursed. Coverage can be backdated up to three months to allow the pharmacy to bill the claim online and reimburse you. Alternatively, you can send your original receipt to the Pharmacare Programs office for reimbursement.

Is eligibility for Nova Scotia Seniors’ Pharmacare Program contingent on giving consent to access your Canada Revenue Agency information or providing proof of income?

Please be aware that the Nova Scotia Seniors’ Pharmacare Program eligibility is not contingent on giving consent to access your Canada Revenue Agency information or providing proof of income. The inability to verify an applicant’s or a beneficiary’s income information will only mean that the premium payable will be based on the maximum premium.

Reimbursement Questions and Answers

How are pharmacies reimbursed for medications dispensed to Pharmacare Program beneficiaries?

The Nova Scotia Department of Health and Wellness negotiates with the Pharmacy Association of Nova Scotia to determine maximum professional fees, allowable mark-ups, and definitions of cost that pharmacies can charge for prescriptions covered under the Pharmacare Programs.

What drug cost does Pharmacare pay?

The Pharmacare Programs pay the actual acquisition cost (AAC) or manufacturer's list price (MLP) for drugs submitted to the Pharmacare Programs, unless the drug has been assigned a Maximum Reimbursable Price (MRP) or a Pharmacare Reimbursement Price (PRP). The Pharmacare Programs also pay a markup on the cost plus a professional fee.

What is the Maximum Reimbursable Price (MRP)?

MRP is the maximum reimbursable price established by the Pharmacare Programs for an interchangeable generic drug. MRP is applied to those drugs which are Pharmacare benefits and have been deemed interchangeable (e.g., brand name drugs and their generic equivalents).

The MRP is the maximum amount that the Pharmacare Programs will reimburse pharmacies for one unit (tablet, capsule, millilitre, etc.) of a drug.

For each interchangeable generic drug category, a maximum reimbursable price per unit (e.g., tablet, capsule, millilitre) is determined by calculating a percentage of the cost of the equivalent brand name drug. As of November 1, 2014, the MRP is based on 25% (oral solid dosage forms) or 35% (non-oral solid dosage forms) of the cost of the price of the equivalent brand drug.

Some generic drugs may have exceptions to the MRP formula, and their MRP will also be included in the Nova Scotia Formulary.

Pharmacies shall not charge any cost difference between the AAC of the drug and amount reimbursed by the Pharmacare Programs unless the beneficiary requests the higher priced drug. If the beneficiary requests the higher priced drug, the extra cost is not counted toward their annual maximum copayment or annual maximum deductible.

Are exemptions to the Maximum Reimbursable Price (MRP) considered?

Yes. Exemptions to the MRP are available for beneficiaries who have experienced side effects with lower cost alternatives. A request must be received from the prescriber detailing the reaction.

What is the Pharmacare Reimbursement Price (PRP)?

PRP is the "special" maximum price assigned to:

  • certain groups of drugs that are similar in therapeutic effect;
  • specific services for which coverage is established;
  • certain unit dose and special delivery formats that are also available in less expensive bulk formats; and
  • certain supplies that are used for the same function.

The PRP is the maximum amount the Pharmacare Program reimburses pharmacies for one unit of a drug (tablet, capsule, millilitre, etc.), device, or service. In the case of methadone, one unit is a milligram.

The PRP is established by the Pharmacare Programs and is published in the Formulary.

Is there a limit on the quantity of drugs that will be reimbursed by the Pharmacare Programs?

Yes. The Pharmacare Programs will reimburse pharmacies for prescriptions for up to a 100 days' supply.

Vacation Supply Exception for Pharmacare Recipients:

  • Seniors’ and Family Pharmacare Program beneficiaries traveling outside the province for more than 100 days will be allowed to obtain three prescriptions for the same medication before leaving Nova Scotia. None of the prescriptions shall exceed a 90 day supply (maximum 270 day supply for three prescriptions). The usual dispensing fee and copayment are to be applied to each of the prescriptions.