Therapeutic Class Pricing (TCP)
Therapeutic Class Pricing (TCP) is being introduced to help ensure your benefits plan remains sustainable while continuing to provide access to safe, effective medications. This pricing model affects how some prescription drugs are reimbursed under your plan, starting with select classes of commonly prescribed medications.
What Is Therapeutic Class Pricing?
Within certain drug classes, there are multiple medications that are all equally safe and effective but where the cost of medications can vary. Therapeutic class pricing (TCP) – also known as reference-based pricing – means your reimbursement for drugs within those classes will be capped at a fixed amount. The table below outlines the therapeutic classes, conditions treated and reference drugs under the CUPE EWBT plan.
Drug Classes and Conditions Treated
Why These Classes?
Within each of these classes, there are many different drugs available for physicians to prescribe, all of which are equally safe and effective. The drugs work the same way in the body and are chemically very similar – for the vast majority of patients, the only difference is cost.
For example: A prescription for a proton pump inhibitor (PPI) means a physician has selected one of the six products listed above. The drug isn’t the only one in the class that can treat those conditions; it’s just the one the physician has chosen.
The reference drug in each class is selected based on several factors, including clinical studies, safety data, utilization, approved indications, expert opinion and cost.
How TCP Works?
For any drug to which TCP applies under the CUPE EWBT Plan, you will be reimbursed up to the cost of the reference product. You will be responsible for covering any difference in cost out of pocket.
For example: Let’s say you are taking Losartan (the generic version of Cozaar) for high blood pressure. Each dose costs $0.31, but the cost of the reference drug is $0.22. In this case, you would be responsible for covering the cost difference $0.09 cents per dose) between the two drugs.
Sometimes the cost differences are small. But in other cases (like Dexilant) which costs $2.30 per dose, compared to Rabeprazole (generic version of Pariet) which costs $0.13, the difference per dose can be significant.
Exceptions
Exception requests will only be considered in rare circumstances where there is clear clinical evidence that the reference drug(s) are not suitable due to documented treatment failure or intolerance to multiple medications. To be eligible for an exception:
- Your pharmacy claims history must show that you have had a clinically appropriate trial of multiple medications, including the reference drug(s)
- Your physician must complete the Request for Exception form, including medical documentation demonstrating an adverse reaction or treatment failure to the various generic medications, including the reference drug(s).
Incomplete or unsupported requests will not be accepted.
Submit the completed form to FACET:
- Fax: 1-844-446-1575
- Email: claims@facetprogram.ca
Have Questions About Therapeutic Drug Pricing?
For more information about the Therapeutic Drug Pricing or need help with the forms.