Prescription Drugs (POC 10)

Purpose

This policy gives direction on the provision of benefits through Program of Choice (POC) 10 (Prescription Drugs).

Policy

Eligibility

1. Clients who are eligible to receive treatment benefits, including prescription drugs, are outlined under Part 1 of the Veterans Health Care Regulations, 3(1) - 3(7).
2. Clients who are eligible for rehabilitation services under the authorization of a Rehabilitation Plan may be eligible for POC 10 benefits if included in the plan.

General

3. POC 10 benefits are prescribed by health professionals authorized to do so under the laws in force in the province/territory or country where the pharmaceuticals are provided. The Department establishes a formulary and includes the following:
   1. Drugs which can only be legally dispensed under the authority of a prescription from an authorized prescriber. These drugs are identified by a Drug Identification Number (DIN) or Natural Product Number (NPN);
   2. Drugs which do not require a prescription by law and can be obtained over the counter. These benefits are identified by a DIN or NPN or a Product Identification Number (PIN);
   3. Extemporaneous compounds are a drug or mixture of drugs prepared or compounded in a pharmacy according to the order of a prescriber, and must not duplicate commercially available drug products available at a lower cost. A compound is not eligible for reimbursement if it contains a non-approved or non-listed active ingredient. All active ingredients in the extemporaneous compound, excluding diluents and bases, must meet all of the following approved reimbursement conditions:
      1. contains regular benefit drug(s), and/or,
      2. special authorization drug(s) for which approval has been granted, and/or,
      3. non-formulary product drug(s) for which exceptional approval has been granted.
   4. Non-drug products traditionally obtained through a pharmacy identified by a DIN, NPN or a PIN. Some non-drug products available through the POC 10 may also be available through another POC such as POC 7 Medical Supplies.
4. Health Canada approves drugs for specific indications included in the drug’s official product monograph which is part of the Notice of Compliance (NOC). Many off-label drug uses are effective, well documented in the peer-reviewed literature, and widely used. Off-label or unlabeled drug use occurs when a drug is used in a treatment regime or patient population that is not included in the NOC, and a drug is used for an indication other than those specifically included in the NOC. The Department may consider approving off-label or unlabeled drug use when one or more of the following criteria are met:
   1. Evidence of use of the drug for the specified condition(s) in Canadian clinical practice (e.g. integration of the drug into clinical practice guidelines);
   2. Evidence that health technology assessment organizations have made recommendations for this specific usage;
   3. Other regulatory authorities have issued approvals for these indications of interest (e.g. US Federal Drug Administration or the European Medicines Agency); or,
   4. Consideration may be given when patients are not adequately controlled with standard of care therapy if the balance of the medical literature supports such a therapy, and there is no significant evidence against its use for the particular condition.

Place of Residence

5. The provision of pharmaceuticals should be applied in a similar manner for all clients regardless of whether the client resides independently in the community or in a long-term care facility.

Generic Drugs

6. Clients are to be dispensed generic pharmaceuticals unless otherwise stated on the prescription and supported with a medical rationale.

Biosimilar Drugs

7. Clients are to be dispensed biosimilar pharmaceuticals when they are available as treatment for their eligible condition(s).

Standard, Special Authorization, and Client Formularies

8. Prescription drugs are available when they have been prescribed and have been accepted for inclusion in the Department’s standard or special authorization formulary, or an individual client’s formulary.

Non-Formulary Products

9. Products that are not included in the Standard Formulary or Special Authorization Formulary can be considered on an individual client basis, based on the specific health needs of the client. These products are called non-formulary products. The authorization of non-formulary products requires an explanation from the authorized prescriber for the client and the need for the product and how it will have therapeutic value. Clients are to be reimbursed the cost of obtaining this information (report) up to the rates noted in the VAC schedule.

Prescription Requirements

10. Prescriptions can be written, verbal or electronic in nature and must be valid in the province/territory/country where the prescribed pharmaceuticals are being dispensed as determined by the dispensing pharmacist.

Extended Supply

11. Clients can receive an extended supply of drugs for a period of up to six months when they have a legitimate reason for needing the quantity requested, such as an extended period of treatment. The request cannot contravene provincial/territorial legislation or that of another country, and the shelf-life of the drug would not be exceeded.
    
    In addition, the client must be stabilized on the drug (i.e. maintenance therapy) and the prescribing health professional must be confident the client is not at risk by dispensing a large quantity of the drug.

Over the Counter Drugs

12. Over the counter medications are eligible benefits if:
    1. the benefit is included in the standard, special authorization, or client’s formulary; and,
    2. the benefit has been prescribed by an authorized prescriber.

References

Veterans Well-being Act

Veterans Health Care Regulations