Medication Costs to Nova Scotia Cancer PatientsImplications to Patients Who are Uninsured or Under-Insured for
Prescription Medications
Report by the Cancer Medication Costs Working Group
of the Cancer Care Nova Scotia Advisory Board of Directors
27 November 2006
SUMMARY:
Cancer patients require comprehensive care that often includes medications for cancer
treatment, symptom management and other supportive care needs. Although some
medications are administered in hospitals or clinics, many medications are acquired by
patients through their local community pharmacy (sometimes referred to as ‘community
pharmacy’) for self-administration. Health care facilities (e.g. hospitals) generally do not
charge patients for medications, but prescriptions filled in community pharmacies are
purchased by patients or their third party insurers. In Nova Scotia, there is wide
variation in the coverage of cancer patients by public or private prescription insurance,
and 24% of patients have no prescription coverage at all. Private insurance also varies
widely in terms of coverage and co-payment requirements for the patients themselves.
For catastrophic prescription costs, even the co-payments may be beyond the patients’
ability to pay. Over half of the Nova Scotia population is either uninsured or ‘underinsured’ for costly cancer medications and current public systems are not adequate to
help many patients in need.
Against this backdrop of variable and inconsistent prescription drug coverage, the field
of cancer treatment is rapidly evolving. New cancer medications are extraordinarily
expensive, often tens of thousands of dollars per year. Many new oral agents have
been released for community pharmacy dispensing, and more are on the way. Health
authorities have responded to this emergent problem by creation of new positions
(Medication Resource Specialist, Patient Navigators) to assist patients to optimize every
opportunity for drug coverage, but this has not been enough. The current systems and
plans are inadequate for the present and not positioned to address the emergence of
new cancer therapies.
Comparisons of prescription costs within Nova Scotia and across Canada provide some
important insights. There is wide variation of reported costs for like prescriptions within
the province. Costs of similar prescriptions in other provinces are frequently lower
under other models for prescription delivery. High-cost drugs, such as many of those
used in cancer care, tend to be lower in cost-regulated provinces (such as Ontario or
Quebec) and lower still in provinces where these drugs are directly dispensed and
distributed by the provincial cancer agencies (e.g. Manitoba, Saskatchewan, Alberta).
High cost drugs for other diseases, such as MS, HIV/AIDS and organ transplantation,
are dispensed through a central process in Nova Scotia, so it makes sense to consider
a similar approach for high-cost cancer drugs.
Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
It is the recommendation of this Working Group of the Advisory Board of Cancer Care
Nova Scotia that the province consider a significant revision to the public prescription
plans in place to support Nova Scotia cancer patients. Changes to current plans, such
as an extension of eligibility criteria for the Drug Assistance for Cancer Patients program
or the creation of a new Working Families Prescription Program, may help with local
access to low-cost supportive care medications but cannot address the anticipated
catastrophic costs for new drugs nor achieve cost-savings through competitive contract
purchasing and provincial management (as illustrated in other Canadian provinces).
This Working Group recommends the creation of a provincial program for centralized
dispensing, distribution and management of cancer drugs, similar to the processes used
for other therapeutic areas with high cost drugs (e.g. multiple sclerosis). The
development and operational over-sight of the NS-CMP will be delegated to Cancer
Care Nova Scotia by the provincial Department of Health. CCNS management would
entail contracting to appropriate vendors to provide competitive drug acquisition
contracts, dispensing functions and provincial prescription distribution. CCNS would
assume responsibility and accountability for designated cancer medication prescriptions
funded by the province through this new program. Changing from current practices
would offer the opportunity for cost savings and ensure access by all Nova Scotia
cancer patients.
Summary of Recommendations:
Development of a Provincial Nova Scotia Cancer Medication Program (NS-CMP)
1. All drugs used for cancer treatment or supportive care during cancer treatment
(funded by public funding, outside those administered in hospital settings) should be
dispensed through a central process, similar to other NS programs such as the MS
program. This would include all prescriptions covered by DACP, Pharmacare and
Community Services for cancer treatment and support medications. This might be
called the Nova Scotia Cancer Medication Program (NS-CMP)
a. The development and operational over-sight of the NS-CMP should be delegated
to Cancer Care Nova Scotia by the provincial Department of Health.
b. The NS-CMP would be integrated into current systems for cancer care delivery.
Methods to enhance efficiencies for acquisition cost and distribution of cancer
drugs should be developed to offset the increased costs of an expanded patient
eligibility. The NS-CMP would assume all patients currently covered by publiclyfunded prescription programs.
c. Drugs covered by NS-CMP would be limited to those used for treatment of the
cancer or symptoms of the cancer or its treatment.
d. The Prescription Drug Distribution Program should be approached to act as the
purchasing agent and negotiator for drug acquisition prices.
e. The other provinces in Atlantic Canada should be approached to join this
program and form an Atlantic Canada consortium for collective purchasing and
contracting.
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
Changes to the Current Drug Assistance for Cancer Patients (DACP) Program
2. The DACP should be expanded to include all Nova Scotia cancer patients who do
not have any prescription insurance and whose prescriptions costs for cancer drugs
are catastrophic (> 4% gross annual family income).
a. Processes must be developed to ensure that cancer patients and clinicians are
aware of the DACP and other funding assistance programs.
Role of the Patient Navigators and Medication Resource Specialist
3. The Patient Navigator (PN) and Medication Resource Specialist (MRS) positions
must be supported and expanded to include coverage across all districts.
Urgency for Decision
4. The decision to address cancer drug costs must not be delayed to wait for any future
federal decision(s) on a National Pharmaceutical Strategy or provincial decision(s) to
reform the provincial prescription insurance plans.
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
Table of Contents
Summary
1
Members of the Cancer Medication Costs Working Group
5
Access to Prescription Insurance in Nova Scotia
6
The Effect of Cancer Medication Costs on Individual Patients
9
How Medication Access Issues Are Managed in the Nova Scotia Health Care System 13
The Cost of Prescription Medications to Cancer Patients in Nova Scotia
17
How Do Cancer Medication Costs in Nova Scotia Compare to Other Provinces?
19
Recommendations
22
References
24
Appendix I.
Common Prescription Costs for Cancer Treatment & Supportive Care Drugs
25
Appendix II.
Comparison of Cancer Prescription Costs in Several Canadian Provinces
November 27, 2006
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
Members of the Cancer Medication Costs Working Group
This Working Group was composed of CCNS Advisory Board Members, CCNS staff
and invited content experts.
CCNS Advisory Board Members
Judith Wesley (Chair)
Brian Lynch
Darlene Morrison (resigned from Board before completion of project)
Jane Mealey (resigned from Board before completion of project)
CCNS Staff Members
Theresa Marie Underhill, Chief Operating Officer
Larry Broadfield, Systemic Therapy Program Manager
Marlene Sellon, Systemic Therapy Program Pharmacist
Invited Content Experts
Meg McCallum, Canadian Cancer Society
Mary Lou Robertson, Medication Resource Specialist, Capital Health
November 27, 2006
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
Part 1. Access to Prescription Insurance in Nova Scotia
Unlike physician services and hospital care, prescription medication costs are not
universally insured for citizens in Canada. The Canada Health Act is not interpreted to
apply to prescription medications. In a study of all Canadian provinces, the Fraser
Group recently published data to explore the impact of ‘catastrophic’ drug costs to
individuals in each province1. It was recognized that public prescription insurance is
provided by the federal government for First Nations citizens and veterans. Provincial
governments provide prescription insurance for seniors and social assistance clients in
all provinces; extended coverage beyond these core groups varies from one province to
another. Private insurance through employers and unions generally cover employees
and their dependents, and some plans extend to cover retirees and their dependents as
well. There are some other private insurance options across the country, including
plans which register individuals. The extent of coverage varies widely across plans,
both public and private, including variance in drugs that are covered, amount of copayment by the insured person, and limits or caps for coverage.
Figure 1
Who Pays for Prescription Drugs in Canada?
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Out of Pocket
Private Plans
Public Plans
Atlantic Canada
Rest of Canada
The burden to individuals for out-of-pocket payment for prescription drugs is
greatest in Atlantic Canada. In this study, the Fraser Group identified that only 2% of
Canadians have no prescription coverage through either public or private insurance. All
of those people without prescription insurance reside in Atlantic Canada. Further, in
Atlantic Canada 25% of the population has no prescription insurance coverage. In
comparison with the other 3 Atlantic Canada provinces, Nova Scotia has 24% of the
population versus 27-28% for the other 3 provinces, possibly linked to the slightly higher
proportion of the population employed in jobs likely to include prescription insurance as
an employee benefit. It is also notable that the financing of drug expenses varies
between Atlantic Canada and the rest of the country: out-of-pocket expenses by
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
patients and their families are 29% of all drug expenses in Atlantic Canada, compared
with only 20% in the rest of the country. Conversely, public plans cover only 32% of all
drug expenses in Atlantic Canada versus 52% in the rest of Canada, and private plans
carry 39% of drug expenses here compared to 28% in the rest of the country (Figure 1).
When examining the impact of catastrophic drug costs, the inequities are even more
pronounced for the excess burden carried by uninsured patients in Atlantic Canada
compared with the rest of the country.
The observations of the Fraser Group are consistent with the findings from the Public
Opinion Survey, commissioned by Cancer Care Nova Scotia in the spring of 20062.
The Public Opinion Survey also noted that 24% of Nova Scotians do NOT have any
prescription insurance. Within Nova Scotia, there is some regional variance, with more
people in the ‘more affluent’ areas (e.g. CEHDHA and CDHA) than in the less affluent
areas (e.g. SWHDHA) reporting they have prescription insurance. Eleven percent have
prescription insurance where they do not pay and the balance (65%) pay a portion of
the cost for their prescriptions. Of those who have prescription insurance (76% of the
total respondents), nearly half (46%) pay a percentage of the total prescription cost,
where 39% pay a fixed amount and 5% pay an annual deductible only.
The Survey also included a personal ‘catastrophic’i prescription cost scenario, (rated in
the scenario as a prescription that costs between $800 and $1000 before insurance
payment). Survey results identified 69% of respondents for who stated that the cost
would cause financial hardship. Not surprisingly, 90% of those who do not have
prescription insurance said that the cost would be a hardship (8% said it would not be a
hardship). Of those who do have prescription insurance, the majority of 61% still said
that the costs would be a hardship, even after the insurance payment, where 34% said
it would not be a hardship. Clearly, the impact of a costly prescription drug would cause
financial hardship to most Nova Scotians, even those with insurance. Like the Fraser
Group study results, this Survey provides some idea of the magnitude of both uninsured
and underinsured patients in this province.
In Nova Scotia, 24% of the population do not have prescription insurance, and
69% of the population judge that an expensive prescription cost would cause
undue financial hardship even with their current prescription insurance.
While there is no ‘average cancer patient’, let us consider an example of drug costs for
a more typical breast cancer patient. Many breast cancer patients are prescribed
Tamoxifen for 5 years, followed by another 5 years of Letrozole (or other aromatase
inhibitor). The tamoxifen is inexpensive, costing this woman about $250 per year. The
next drug costs considerably more, at about $2,200-$2,450 per year. If this patient
recurs with metastatic disease, she could be offered treatment with capecitabine for the
next 4 to 6 months, at about $1000 per month. Thus, the monthly prescription costs for
The term ‘catastrophic’ is hard to quantify, but one measure could be an expense that exceeds 3 to 4%
of family income, as defined by the Income Tax Act for Medical Expenses1. The National Pharmaceutical
Strategy3 recommends two different models for catastrophic drug costs, either a fixed percentage of 4.3%
of family income, or a variable percentage increasing as family income increases.
i
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
this patient could begin at about $20 for Tamoxifen, increase to $200 when switched to
Letrozole, and then jump to $1000 if Capecitabine is used. In the future, new biologic
agents are expected to be available for breast cancer (e.g. Lapatinib) at a monthly cost
that could be $3,500 to $7,000 (based on similar drugs recently released in Canada). If
these prescription costs are paid out-of-pocket (i.e. the patient has no prescription
coverage), one can see how a manageable cost could quickly escalate to a catastrophic
cost.
The costs for commonly used cancer medications can range from $10 to $3,500 per
prescription (Appendix I). Depending on the patient and family income, some of these
medication costs may be managed by the patient and other may be truly ‘catastrophic’.
These costs are taken from actual prescriptions reported by patients or community
pharmacies. Since there are no prescription cost regulations in Nova Scotia, prices for
the same prescription can vary widely from one pharmacy to the next. As a rule,
patients who pay cash for prescriptions tend to pay the highest prices, whereas third
party insurers demand lower prices. It is ironic that the uninsured patients often pay the
highest prices for like prescriptions. In Appendix I, sample prescription costs varied by
up to $390 from one pharmacy to the next for a one month supply of medications. Cost
variances are particularly notable for the high cost or catastrophic cost medications.
Clearly, there must be some consideration of the cost inequities and systems
implemented to address these variances toward the lowest possible price, especially for
the most financially-vulnerable cancer patients in our society.
In Nova Scotia, the cost of prescriptions can vary by 10-20% (and up to 33%)
depending on where the prescription is filled, and by whether the prescription is
paid by a third party or directly by the patient. Most patients do not understand this
variation in prescription prices. Price variation appears to be greatest for the new, high
cost medications.
November 27, 2006
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
Part 2. The Effect of Cancer Medication Costs on Individual Patients
The effect on individual patients who lack adequate prescription coverage is more than
just statistics and numbers. This problem affects real Nova Scotians who must not only
cope with the devastation of cancer, but also with a system that lets them down during
the worst of their crisis. Here are some actual stories of patients recently seen by our
front line care givers.
Story #1- Mr. B.
Mr. B is in his 30’s and has a brain tumor. He was diagnosed more than 6 years ago
and at the time of his diagnosis there were few treatment options available. He was
newly married at the time of his diagnosis, and his wife took a leave of absence from
her job to care for him due to his frequent seizures. They soon exhausted their savings
and turned to a line of credit to top-up her short-term leave pay and try to meet their
basic expenses.
Within months, Mr. B’s wife learned her company was downsizing and she would be laid
off. Their debt increased as she looked for work. She lost her health benefits and any
new employment would not cover medications related to Mr. B’s tumour as it was a preexisting condition. Mr. B. couldn’t work because of ongoing cognitive symptoms and he
didn’t have LTD benefits with his former job. His started receiving CPP Disability
benefits of approximately $750 per month.
Mr. B’s wife eventually found a new job with a moderate income. The prescription
medications needed to control Mr. B’s seizures and other symptoms were more than
$400 each month but they managed these costs while paying down their debt. Mr B’s
tumour and symptoms were stable.
A few months later, Mr. B started to have more memory loss, anxiety, and more
difficulty understanding others. His tumour was growing. He was told he had no more
than two years to live. The only treatment clinically proven to slow the growth of the
tumour and provide a chance at extending his remaining time was an oral
chemotherapy drug given in conjunction with radiation therapy. It costs approximately
$3,000 per month. On hearing this news his wife began to cry.
Mr B and his wife met with the Medication Resource Specialist (MRS), who assessed
their situation. Although Mr. B did not have access to his wife’s health insurance, her
income made him ineligible for any public prescription program. The MRS helped them
to apply to a Patient Assistance program run by the pharmaceutical company that
produces the drug.
This particular Patient Assistance Program offered to cover the 2nd and 3rd month of
treatment if Mr. B paid for the 1st month’s prescription in full and provide a copy of the
receipt. Likewise, the program would supply the 5th and 6th months’ supply after the 4th
month was purchased by Mr. B. Anxious to start treatment and fearing loss of any
assistance altogether, the couple considered turning to their family to pay the first
November 27, 2006
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
month. In the end, the couple decided to appeal and the MRS helped them with the
appeal process. After some negotiation, the program supplied the full six months of
drug at no cost. Mr. B’s wife admitted that if she had applied to the Patient Assistance
program herself, she would not have known how to appeal the initial decision nor had
the energy to pursue the company’s complicated appeal process. She would have
“begged to family” for support, but she did not know if they would have been able to
help.
Story #2- Ms T.
Ms. T. is a 48 y.o. woman with a long history of cancer in the head and neck. She has
undergone multiple surgeries and has lost part of her face. Her spouse left her shortly
following her first surgery. Although she had worked at a good job for more than 15
years, she had only a small LTD pension and no accompanying drug or health benefits.
For the past three years, her total monthly income with CPP Disability has been a little
over $1000 per month.
Ms. T. called the Medication Resource Specialist (MRS) on the advice of her oncologist.
It had been recommended she switch to an expensive antibiotic to control recurrent
infections, resulting from her extensive surgery. She had been using a different, less
expensive antibiotic, but this was no longer working. Up to this point, Ms. T. had
managed prescription costs on her own and had never pursued drug funding
assistance. She turned to her family doctor for samples occasionally or stretched her
medications to make due. At one point, she was given a prescription for a new, more
expensive antibiotic that she could not afford, and she decided to go without this
treatment. Too ashamed to tell her family doctor, she continued to use the ineffective
(and less expensive) antibiotic. She was later admitted to hospital with an infection and
stayed three weeks.
Ms. T. was referred to the Medication Resource Specialist (MRS) for assessment. The
MRS determined that Ms. T. was eligible for the Drug Assistance for Cancer Patients
(DACP), and would have been eligible for the past three years. On assessment, it was
determine that, in addition to the costly antibiotic, Ms. T actually had nine other
prescribed medications that she took regularly, with a monthly bill of approximately
$150. Most of these medications could be covered by the DACP. The MRS helped Ms.
T to apply for the DACP. She was approved and enrolled the next day. When Ms. T.
was asked why she had not enrolled in the DACP program, she stated she had never
heard of it and never thought she needed it. She did not recall ever being told of the
DACP program while in hospital.
Story #3- The J Family
This family was referred to the Medication Resource Specialist (MRS) for assessment.
This 58 y.o. patient had a long history of chronic illnesses and more recently cancer with
metastases. He had finished radiation therapy and was soon to begin systemic
treatment. The patient was struggling to pay for multiple medications, including some
new medications for cancer treatment, and prescription costs were causing stress for
the family. The MRS met with the family and reviewed the medication list available at
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
that time. Following a consultation with a local pharmacy, the MRS estimated the total
retail cost of the patient’s medications was almost $1000/month. The patient had
‘shopped around’ different pharmacies for less expensive prescription costs, but this did
not reduce costs to an affordable level. He got samples when he could from his family
doctor or specialists, but these were not always available. His spouse worked
seasonally and her income averaged approximately $16,000/year. At the time of their
assessment she was working. The patient received CPP Disability at approximately
$800/month. They did not have drug benefits. Their son, with a young family of his
own, had taken a second job to help his father pay for the medications but could no
longer keep up the pace of two jobs and caring for his own family. The patient’s wife
was embarrassed at the level of support needed from their son and was losing sleep
worrying about the impending cost of cancer-related medications.
The only form of public prescription coverage that would potentially cover all the
patient’s medications was through Income Assistance. Although not eligible for income
benefits, the MRS determined that the patient should have been eligible for Extended
Pharmacare under the NS Department of Community Services (i.e. just drug coverage).
The MRS provided the family with information on the IA program, a list of what to
provide during the call (e.g. SIN number, income amounts, etc) as well as a cover letter
of support and an approximation of the medication costs.
The patient made the application via phone and was told he did not qualify. The Intake
Worker would not accept an application limited to Extended Pharmacare but would only
process an application for full income assistance benefits (for which he did not qualify).
The son attempted to follow up his father’s phone call, but was denied his requested
appointment and told to call the Canadian Cancer Society for help (they do not assist
with drug costs). He called the MRS for further assistance. The MRS, patient and
patient’s son pursued this application with the Area Manager of the Dep’t of Community
Services over the next 2 months. Eventually, the patient was approved for Extended
Pharmacare benefits, but not before the patient had paid over $2600 more for
prescription costs. As a result of this complicated and contentious case, the Central
Region Office of Community Services agreed to have the MRS present to their staff on
medication funding and open a dialogue to target areas for quality improvement in their
phone assessments.
Story #4- Wilma (from one of the Cancer Patient Navigators):
WK (Wilma) is forty-five years old and was diagnosed last fall year with a rare type of
liver cancer called cystadenocarcinoma. She was metastatic at diagnosis and offered
palliative treatment with the drug Capecitabine (Xeloda®). She was employed as a
waitress and her husband is seasonally employed as a construction worker. They had
no insurance and the family income was approximately $24,000. Therefore, Wilma did
not qualify for the provincial Drug Assistance for Cancer Patients program. This drug
would cost about $800 for each cycle. The Patient Navigator (PN) was contacted by the
Medication Resource Specialist (MRS) regarding funding for the medication. The
oncologists did not want to delay treatment but there were no funds to pay for the
medication. The PN was able to cover the costs for the first prescription with charitable
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
funds while a deal was being worked out for a compassionate program with the
pharmaceutical company. Otherwise, Wilma’s treatment would be delayed. The PN also
set up financial assistance to help the family with cancer supportive care medication
costs through a local charitable fund. There would be a limit on how long this help would
be available. Wilma was forced to continue to work as a waitress part-time due to her
financial situation, even though her treatment was palliative in nature.
In August her disease progressed. After a lengthy hospitalization, she was discharged
home on numerous supportive care medications. Her initial prescriptions cost $1740 on
discharge from the hospital. The PN received a call from the drug store about bill
payment. Those prescriptions were paid by a local fund set up the help cancer patients
in the area. (The drug store raised $800 to help Wilma as well.) By month’s end, her
prescription costs were up over $5000. The PN advised the palliative care physician to
apply to the pharmaceutical company’s compassionate program for a new symptom
management drug, when it was clear that the patient would continue on this drug. The
Navigator also advised the patient’s husband to file a claim with Community Services.
Wilma’s drug costs were such that the family income was lowered to the point to allow
her to qualify for their Extended Pharmacare Program. On top of this, the family had
oxygen and hospital bed rental expenses.
The PN then received a call from Wilma’s husband that he had a chance to go back to
work. The increased income would probably disqualify Wilma from Community Services
support. The husband said that the strain of the past year has been extremely difficult
and both he and Wilma both felt that going back to work would be mentally beneficial for
him. Now the PN is working on how to maintain the drug coverage for Wilma – hoping
that she can keep her benefits. This is a terrible choice for her husband. The system
does not support working families in a time of crisis. If Wilma’s husband goes back to
work and she loses her coverage, this will negate any income he can earn, and perhaps
more.
These stories are complicated, and illustrate a variety of means and processes used by
the MRS and PNs to help patients navigate through a bureaucratic maze to acquire
coverage for their cancer treatment medications (and other medications for other
concurrent diseases). Most patients could not hope to succeed with the many different
approaches- and many choose to pay for medications on their own, or to go without.
Difficult application and appeal processes generally necessitate the involvement of a
knowledgeable health professional to help individual patients. Most health
professionals do not themselves understand these systems and cannot offer much help
to their patients. We need to sustain this type of special expertise as long as the
application and appeal processes remain so complicated and ‘user-unfriendly’.
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
Part 3. How Medication Access Issues Are Managed in the Nova Scotia Health Care
System
Clinical care of cancer patients can be impacted by many issues, including patients’
financial ability to pay for their prescription medications. This has a significant impact
on the care of patients and the operation of the health care system. Often, clinicians
must refer their patients to other health care professionals (e.g. social worker,
Medication Resource Specialist, Patient Navigator) for assistance in resolving
prescription coverage, in order to continue the timely treatment of the cancer and
symptoms for the patient. There is incomplete data on how much this impacts the
quality and timeliness of cancer patient care, but some information helps to inform this
issue. One such piece of information comes from the formal evaluation and ongoing
experience of the Cancer Patient Navigators in 5 of the district health authorities3. In
the formal evaluation, patients were asked to identify ways in which the Patient
Navigator (PN) helped them. Thirty one percent of respondent patients answered that
they received help with funding for drugs and supplies. When asked about their issues
and concerns during their cancer experience, 38% of respondent patients identified
financial concerns. Lack of prescription drug coverage would be included as one
financial concern in this evaluation. Resolution of the financial concerns, by the efforts
of the PN, was only successful for some patients. The gap between the need and
resolution of financial concerns was 23% in the formal evaluation survey, partially due to
lack of adequate resources. This was the largest measured gap between any need and
resolution by the Patient Navigators.
When the specific data was reviewed in the PN database, 13% of referrals during the
evaluation period were for financial assistance, and only 2% of referrals were for
assistance with drug coverage. While it was noted in the evaluation that the needs
appeared greater when patients were carefully questioned (the financial concern need
was only 6% upon initial report, but increased to 23% when probing questions were
included). This observation is repeated in a more recent view of the PN database. In
354 PN referrals over 6 months in 5 DHAs, 42 (12%) included a drug cost concern. The
PN’s noted on interview that although medication funding issues do not present as
frequently as other needs, when they do arise they consume inordinate amounts of time
that take away from other activities.
In Capital Health, the largest health care district, a significant increase in the number of
medication referrals over a three year period as well as feedback from staff on the
increasing complexity of medication funding, moved the department to jointly fund a
pilot project of a Medication Resource Specialist (MRS) to assist patients in the Cancer
Care Program acquire appropriate coverage for their cancer treatment medications.
This position started in September, 2005. This role helps patients explore all available
prescription coverage (public and private insurance), as well as other routes to acquire
the medications (such as compassionate coverage programs offered by some drug
companies).
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
In the first year of the MRS Pilot Project, 355 patients were referred for help with the
cost of their cancer medications. Most of these referrals (74%) came from the Nova
Scotia Cancer Centre (NSCC), the largest outpatient treatment site for cancer patients
in the province. Of the 1048 new patients seen in the NSCC over the past year, 24%
required a referral to the MRS. An evaluation is underway conducted using data from
September 1/05 – June 30/06 (n=260). Of these patients, the reasons for referral are
identified and described in Table 1 and the medications for which the patients needed
financial assistance are listed in Table 2. On assessment, 42% of these patients had
previously been unable to afford other, often non-oncology medications and had used a
variety of methods to cope with medication costs (Table 3), several of which
compromised their clinical care. For example, 16% only filled part of their prescription,
12% rationed their drug supply, and 6% simply did not take the drug ordered.
The MRS uses several different types of interventions, many patients receiving more
than one kind of intervention. Of the 260 patients, 21% had no access to any form of
drug coverage and there were no affordable solution for these patients to access their
drug therapies. Access to Pharmacare for Nova Scotians under 65 is based on income,
and data from the MRS pilot is showing that the majority of patients referred who are not
eligible for Pharmacare have family incomes in the range of $20-29,000/year.
Table 1. Reasons for Referral to CDHA Medication Resource Specialist
Reason for Referral
Cannot afford medications
Navigate insurance/Verify coverage
Cannot afford copayment
Eligibility assessment/Information
Help with Pharmacare enrollment
Pharmacare appeal
Reassessment for hospital coverage
Compassionate Drug Program assistance
Insurance appeal
Insurance cap reached
November 27, 2006
%age of Referrals
30%
22%
21%
10%
9%
3%
3%
2%
2%
1%
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
Table 2. Types of Medications Requiring Financial Assistance on Referral to MRS
Type(s) of Medication(s)
%age of Referrals
Antiemetics/Supportive Medications
Multiple Medications
Breast Cancer Hormones
Pain Medications
Prostate Cancer Hormones
Fragmin (Anticoagulant)
Temozolomide
Other Medication
Imatinig (Gleevec®)
Capecitabine (Xeloda®)
Interferon
Eprex/Aranesp
None Prescribed at time of referral
25%
11%
9%
8%
7%
7%
7%
6%
4%
4%
2%
2%
8%
Table 3. Coping Methods Reported by Patients Prior to MRS Referral
Free drug samples from Family Doctor
Borrowing money
Filling only part of the prescription
Refinancing/cashing in investments
Rationing/going without essential items
Rationing drug(s)
Taking lower doses/less effective drugs
Not taking drug
22%
19%
16%
14%
14%
12%
8%
6%
Table 4. Types of Interventions by MRS to Address Medication Access Issues
Access Compassionate Use Program
Pharmacare enrollment
Navigation of insurance/Verification of coverage
Provide information only
No eligibility/no insurance
Referral to another service
None required
Assist access to Special Authorization process
Advocacy linked to medication funding
19%
17%
11%
10%
21%
7%
6%
6%
2%
There are 6 different paths to achieve drug coverage through publicly-funded
prescription programs in Nova Scotia (seniors’ Pharmacare, community services, Drug
Assistance for Cancer Patients, the MS program, the Diabetes program and a children’s
program). Each process has different processes, different policies, different financial
eligibility criteria and poor communication across these programs. Cancer patients may
need to access more than one program if they have different co-morbidities (e.g.
diabetes). Despite the availability of these programs, due to the income eligibility
frameworks many needs remain unmet in the cancer population and patients can’t
access the funding they need. The MRS has also observed that the patients referred
are usually unaware of the Pharmacare programs that do exist and need help to
determine which programs to access or if they are even eligible. She has also noted
November 27, 2006
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
that the information that is available on Pharmacare brochures and the internet is
difficult for patients to understand, and that there is a high degree of public
misinformation. As identified in Table 4, the MRS also helps many patients to access
pharmaceutical-sponsored Compassionate drug (i.e. free drug) programs and to
navigate their insurance. These industries are becoming more complex and patients
require assistance to ensure their coverage occurs in a timely and appropriate manner.
The need for specialized professionals to help cancer patients (or any other patients) to
optimize their use of these various program is pronounced and supported by the data
emerging from this pilot program.
With data from 6 of the health care districts in Nova Scotia, it is reasonable to draw
some conclusions. The impact of prescription coverage problems, is a significant
barrier to effective patient care. Many patients are unaware of prescription drug
coverage available to them and simply need help to explore and utilize coverage
options available to them. Other patients, without formal coverage, may qualify for an
industry-sponsored compassionate coverage program that limits or eliminates drug
costs to their pocket. Helping patients to find and exploit these options takes time and
specific knowledge of health care professionals, but otherwise does not require any
changes to the system. When these groups are managed, however, there are still
several patients faced with prescription costs beyond their ability to pay. At present
their options include: coverage by charitable foundations within Nova Scotia, such as
Tits ‘n Glitz and the Bikers’ Memorial Fund (which are not a secure form of coverage
and have a cap on how much assistance they can provide); liquidation of personal
assets to pay for prescriptions; quitting employment to qualify for Pharmacare through
Social Assistance; or choosing not to take the medication. We have no data on how
many patients opt for several of these choices.
Assisting patients and families to access existing services for coverage of cancer
treatment drugs is a key role for the Patient Navigators and Medication Resource
Specialist. Many patients would not be able to access these drugs without this
professional assistance.
November 27, 2006
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
Part 4. The Cost of Prescription Medications to Cancer Patients in Nova Scotia
The public plans available to Nova Scotia cancer patients include Community Services
(for patients who qualify for inclusion in the social assistance program), the Drug
Assistance for Cancer Patients- DACP program (which extends coverage to cancer
patients with an annual gross family income not exceeding $15,720), and the
Pharmacare program for seniors (65 years of age and older). Another publicly-funded
program for selected high-cost drugs is administered through the QEII Health Sciences
Centre. This plan supplies expensive drugs for Multiple Sclerosis, HIV/AIDS, organ
transplant patients and some other designated agents. Cancer patients sometimes
access the drug Filgrastim (Neupogen®- for prevention of neutropenia) through this
program. As noted above the public knowledge of these various programs is poor and
the eligibility criteria are very inconsistent and restrictive.
The cost of cancer drugs to the public prescription plans are predominantly covered
through the Pharmacare program (Table 5). The Community Service program for
patients on social assistance actually has consistently cost the province more for cancer
treatment drugs than the DACP program (which is specifically designed for cancer
patients).
Table 5. Costs of Cancer Treatment Drugs1 Paid by Public Prescription Plans in NS
Fiscal Year
DACP2
Community
Services
Senior’s
Pharmacare
Total Public Rx
Costs
2002-03
2003-04
2004-05
2005-06
$165,000
$144,000
$162,000
$312,000
$194,000
$290,000
$254,000
$478,000
$4,737,000
$4,938,000
$5,196,000
$5,622,000
$5,096,000
$5,372,000
$5,612,000
$6,420,000
Estimated
Non-Public Rx
Costs3
$5,943,000
$6,211,000
$6,830,000
$7,793,000
1. Analysis of drugs for disease management; other symptom management drugs are not
included in this analysis, due to lack of linkage between expenditure and clinical indication (e.g.
unable to determine if analgesic used for cancer pain or other pain)
2. DACP = Drug Assistance Program for Cancer Patients
3. Annual cost of cancer drugs dispensed through community pharmacies estimated by IMS- this
estimate excludes public expenditures and includes private insurance and out-of-pocket costs
for patients
The data on publicly-funded cancer prescription costs allows for analysis of costs by
individual drug or by drug categories. In Figure 2, the prescription costs are divided into
4 broad categories: Prostate cancer hormones, Breast cancer hormones, Cytotoxic
chemotherapy, and Biologic agents. It is clear that the largest single cost category is
the group of prostate cancer hormones (approximately $4 M per year) but this category
has not changed over the past 4 years. The other 3 categories, while smaller, are each
increasing over time. Breast cancer hormones include the group of aromatase
inhibitors (e.g. Anastrozole, Letrozole, Exemestane), which are driving the increasing
costs in this category (approximately $1 M in 2005-06). Cytotoxic chemotherapy drugs
comprise a large group of drugs, most recently including two expensive agents,
Capecitabine and Temozolomide. The category to watch in the future is Biologic
agents. In this category, the addition of Imatinib has resulted in a modest cost increase.
November 27, 2006
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
Into the future, several new cancer drugs are expected to join this category at
substantive cost. Some of these drugs are Erlotinib (lung cancer), Sorafenib (kidney
cancer), Sunitinib (GIST), lapatinib (breast cancer) and lenalidomide (myeloma). Each
of these drugs will cost $10 thousands per patient.
Figure 2.
Pharmacare Drug Costs by Category
$7,000,000
$6,000,000
$5,000,000
$4,000,000
$3,000,000
$2,000,000
$1,000,000
$0
02-03
November 27, 2006
03-04
04-05
05-06
Prostate Cancer Hormones
Breast/Gyne Cancer Hormones
Cytotoxic Chemotherapy
Biological Agents
Page 18
Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
Part 5. How Do Cancer Medication Costs in Nova Scotia Compare to Other Provinces?
In Nova Scotia, cancer drugs cost more than other provinces. The price for
individual prescriptions are generally higher in Nova Scotia than other provinces, for the
same medications. Although there is no data from other Atlantic Canada provinces, we
understand that prescription costs for cancer drugs are similar to Nova Scotia. Why is
Nova Scotia (and Atlantic Canada) less cost-efficient than the rest of Canada?
In Ontario, Quebec and Saskatchewan, the public prescription plan is cost-regulated
through a provincial formulary that includes unit price maximums for each item covered
and requires that the lowest price generic alternative is used for pricing. Dispensing
fees and allowable mark-ups are designated, and in Ontario and Quebec there is
consumer protection legislation that includes regulatory penalties to pharmacies for
exceeding the maximum formulary prices for any patient, regardless of their prescription
insurance status (unless patients explicitly agree to pay more for name brand drugs or
physicians specify name brand drugs). That is, even patients who pay for their
prescription out of pocket (i.e. no insurance) are guaranteed a maximum price for any
given prescription. In Nova Scotia, cash-paying customers may be charged any
dispensing fee (usual and customary fee for each pharmacy) and any mark-up charge
without regulatory restrictions.
In Manitoba, Saskatchewan (for specific cancer treatment medications), Alberta and
British Columbia (specific drug costs not available for Alberta and BC), prescriptions for
cancer drugs are filled by the cancer agencies and delivered to patients across the
province. This allows the cancer agency to negotiate for competitive prices through
direct purchasing, and to eliminate dispensing fees (although mailing costs are not
included in this analysis). Since contract prices are confidential, data is presented only
as approximate percentages of the NS costs to respect confidentiality. In Alberta, the
Alberta Cancer Board states that they achieve competitive prices wherever possible and
their prices are similar to other western Canadian provinces reported herein. There are
two significant drug cost advantages by this system:
 Competitive contract pricing to provincial cancer agencies is lower than most
wholesale prices paid by Nova Scotia community pharmacies
 Drugs for which there are no competitive prices (i.e. single-source products with
fixed list prices, no generic competitors and no preferential contract pricing) cost less
for provincial cancer agencies due to the lack of mark-up costs by either a
wholesaler or the community pharmacy (as is common practice in Nova Scotia). The
mark-up costs can be substantive for high-cost medications.
The costs of average prescriptions in NS are compared to other provinces in Appendix
II. This analysis illustrates comparative costs between NS and the two other systems
for prescription pricing and funding (described above). The provinces with costregulated provincial formularies are 10-20% less costly for like-to-like prescriptions
when compared to reported prices in Nova Scotia. These savings will vary due the
price variances within Nova Scotia, and the timing and impact of newly-released generic
products (e.g. Bicalutamide, Ondansetron). In time, the cost of each generic product
November 27, 2006
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
will become similar across provinces, but mark-up charges will persist to generate cost
variances. The provinces with centralized dispensing and distribution through their
provincial cancer agencies have realized considerably greater cost-savings for liketo-like prescriptions. For instance, in Saskatchewan there is competitive contracting for
selected drug groups to further reduce costs to patients/the public system. The prostate
hormones are contracted by therapeutic group to ensure the lowest cost for the
province, and patients may be substituted for an equivalent but less costly product
within the category of drugs. For this drug group alone, the Saskatchewan costs are
60% lower than Nova Scotia (this could represent a cost-saving to NS of approximately
$1.5 Million- see Figure 2 for current NS costs).
The precedent for centralized distribution of high-cost drugs has already been
established in Nova Scotia with drugs for MS and other designated high-cost drugs. A
centralized and cost-controlled process for cancer drug dispensing and
distribution in Nova Scotia could save millions of dollars from the current public
prescription expenditures and offset any costs incurred to extend coverage to the
uninsured and under-insured patients described above.
Beyond Nova Scotia, it would make sense to approach the other Atlantic Canada
provinces to build a consortium for common drug acquisition and dispensing. None of
the 4 Atlantic Canada provinces have a centralized process for purchasing and
dispensing cancer treatment drugs. These 4 provinces appear to have the highest
costs for individual prescriptions and proportionately more cancer patients to serve.
The incidence and prevalence of cancer in Atlantic Canada is higher than the rest of the
country5. The purchasing and contracting power of a single process for all of Nova
Scotia, to support needs for a population of 1 million, would be even stronger if this
process were to represent all of Atlantic Canada, with a combined population of 3
million people (which is about 10% of the Canadian population). A larger critical mass
of sales generally commands a stronger competitive contracting position. An Atlantic
Canada coalition could be developed between the provinces and tested for outcome
effectiveness in collaboration with the new National Collaboration Centre on
Determinants of Health, hosted at St. Francis Xavier University.
Among the 4 Atlantic Canada provinces, Nova Scotia has the most developed
infrastructure to support a centralized process for common contracting and clinical
support for a cancer drug dispensing and distribution system. Cancer Care Nova Scotia
is a leading agency for development and implementation of clinical practice guidelines,
new cancer drug guidelines and provincial policies and procedures for systemic therapy,
all of which provide key infrastructural support for a centralized prescription process.
The Provincial Drug Distribution Program of the Nova Scotia Department of Health is
the drug contracting and distribution group that supports all health care districts in the
province, and could be well-positioned to expand services to support the demands of a
province-wide or Atlantic Canada-wide purchasing program. With leadership from Nova
Scotia, a combined process could save costs for all four Atlantic Canada provinces, and
perhaps be more cost-efficient than 4 separate provincial processes.
November 27, 2006
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
To summarize and illustrate how costs to individual patients differ from province to
province, let us return to our breast cancer patient example from Part 1. In the 4
western provinces, this patient would have received her cancer treatment drugs through
the provincial cancer agency. Although it may be less convenient for her to pick up her
prescriptions at the local cancer centre or through registered mail, there would be little
or no cost to her out-of-pocket.
In the central provinces, Ontario and Quebec, this patient would have filled her
prescription at the local pharmacy. She would have had to pay some portion of the
cost, or all of the cost if she has no prescription insurance. The total cost for each
prescription would be less than she would have paid in Nova Scotia. Unlike Nova
Scotia, in these other provinces there is an option for her if the costs become
unaffordable. This patient has the option to apply for public prescription coverage that
is based upon her ability to pay. For instance, if she were employed with a modest
income in Ontario, she could apply to the Trillium program (an extension of Ontario
Drug Benefit) and could receive prescription benefit similar to those offered for seniors
after she has paid an annual deductible based on her income. (Those with higher
incomes have higher deductible limits.) While she could likely afford the Tamoxifen (at
$20 per month) and possibly afford the Letrozole (at $200 per month), it is likely she
could not afford the Capecitabine (at $1000 per month) and her benefits would take
over once she has paid her share. Similar programs are available in Quebec, and in the
western provinces (for non-cancer medications).
In Nova Scotia, this same breast cancer patient may need to appeal to charitable
groups or foundations for money. She may face a choice between maintaining her
employment or quitting work to qualify for Community Services prescription benefits.
She may choose to forego filling prescriptions she cannot afford and hope the cancer
does not progress or that she does not die. Options in Nova Scotia are often
demeaning to cancer patients, as well as less cost-effective. It is time for a change- our
patients deserve it and the health care system cannot afford to continue with the current
systems.
November 27, 2006
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
Recommendations:
Development of a Provincial Nova Scotia Cancer Medication Program (NS-CMP)
1. All drugs used for cancer treatment or supportive care during cancer treatment
(funded by public funding, outside those administered in hospital settings) should be
dispensed through a central process, similar to other NS programs such as the MS
program. This would include all prescriptions covered by DACP, Pharmacare and
Community Services for cancer treatment and support medications. This might be
called the Nova Scotia Cancer Medication Program (NS-CMP)
a. The development and operational over-sight of the NS-CMP should be delegated
to Cancer Care Nova Scotia by the provincial Department of Health. Cancer
Care Nova Scotia has the necessary leadership to develop and maintain the
necessary provincial infrastructure and the cancer-specific expertise to manage
ongoing clinical challenges as costly new cancer medications are entering the
Canadian marketplace.
b. The NS-CMP would be integrated into current systems for cancer care delivery,
to ensure patient safety and efficiency in dispensing and distribution of
medications for cancer treatment and supportive care. Methods to enhance
efficiencies for acquisition cost and distribution of cancer drugs should be
developed to offset the increased costs of an expanded patient eligibility (all
uninsured or under-insured cancer patients in Nova Scotia). The NS-CMP would
assume all patients currently covered by the DACP program, and cancer patients
covered by Pharmacare and Community Service programs. Cost-savings
achieved through competitive contract purchasing and elimination of mark-up
charges would extend to all public cancer treatment prescription costs.
c. Drugs covered by NS-CMP would be limited to those used for treatment of the
cancer or symptoms of the cancer or its treatment. In cases where it is uncertain
that the drug is intended for treatment of cancer or symptoms, the clinician
support for the NS-CMP will identify the intended use.
d. The Prescription Drug Distribution Program (i.e. the provincial hospital drug
purchasing group) should be approached to act as the purchasing agent and
negotiator for drug acquisition prices.
e. The other provinces in Atlantic Canada should be approached to join this
program and form a consortium for collective purchasing and contracting. With
leadership from Nova Scotia, a consortium could further benefit all partners
through stronger competitive pricing for a larger market, and through consistent
processes and clinical support to avoid costly duplication of services.
November 27, 2006
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
Changes to the Current Drug Assistance for Cancer Patients (DACP) Program
2. The DACP should be expanded to include all Nova Scotia cancer patients who do
not have any prescription insurance and whose prescriptions costs for cancer drugs
are catastrophic (> 4% gross annual family income). The DACP should also be
reorganized to cover catastrophic costs which exceed private prescription insurance
limits or drugs not covered by the patient’s prescription plan. Ideally, DCAP could be
rolled into a wider provincial prescription program to provide coverage for all
catastrophic prescription needs.
a. Processes must be developed to ensure that cancer patients and clinicians are
aware of the DACP and other funding assistance programs.
Role of the Patient Navigators and Medication Resource Specialist
3. The Patient Navigator (PN) and Medication Resource Specialist (MRS) positions
must be supported and expanded to include coverage across all districts. Without
these ‘system experts’, patients will continue to be unable to navigate public and
private insurance options to ensure coverage of necessary cancer medications.
Urgency for Decision
4. The decision to address cancer drug costs must not be delayed to wait for any future
federal decision(s) on a National Pharmaceutical Strategy or provincial decision(s) to
reform the provincial prescription insurance plans.
November 27, 2006
Page 23
Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
References
1. Drug Expense Coverage in the Canadian Population: Protection from Severe Drug
Expenses. Fraser Group & Tristat Resources, August 2002, for the Canadian Life
and Health Insurance Association
2. 2006 Public Opinion Survey. Corporate Research Associates Inc. March 2006, for
Cancer Care Nova Scotia (CCNS001-1000)
3. National Pharmaceuticals Strategy Progress Report, Federal/Provincial /Territorial
Ministerial Task Force. June 2006
4. Cancer Patient Navigator Evaluation: Final Report. Corporate Research Associates
Inc. March 2004, for Cancer Care Nova Scotia (461-7005Q)
5. Canadian Cancer Statistics 2006, Canadian Cancer Society
www.cancer.ca/vgn/images/portal/cit_86751114/31/21/935505792cw_2006stats_en.
pdf.pdf
November 27, 2006
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Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
(1) Appendix I. Common Prescription Costs for Cancer Treatment & Supportive
Care Drugs
NS High
NS Low
Medication (Approximate cost per month)
Cost
Cost
Cancer Treatment Medications
Anastrozole (Arimidex®) 1mg - 30 tabs
$175.56
$164.14
Bicalutamide (Casodex®) 50 mg - 30 tabs
$223.84
Bicalutamide (Generic) 50 mg - 30 tabs
$132.14
Buserelin (Suprefact®)
6.3 mg syringe * 2 Months’ Treatment
$851.17
$722.49
9.45 mg syringe * 3 Months’ Treatment
$1,324.40 $1,060.09
Capecitabine (Xeloda®)
150 mg- 28 tabs
$73.76
$64.48
150 mg- 56 tabs
$137.40
$118.54
500 mg- 56 tabs
$439.45
$379.44
500 mg- 84 tabs
$651.58
$561.35
Exemestane (Aromasin®) 25 mg - 30 tabs
$199.62
$173.80
Interferon (Intron A ®)
18 MU vial
$235.44
30 MU
$382.27
60 MU
$796.95
Imatinib (Gleevec ®) 100 mg – 30 tabs
$3,477.68 $3,091.05
Goserelin (Zoladex®) 10.8 mg syringe
$1,266.36 $1,103.62
 3 Months’ Treatment
Letrozole (Femara®) 2.5mg - 30 tabs
$205.14
$183.27
Leuprolide (Eligard®)
22.5 mg syringe * 3 Months’ Treatment
$1,121.80 $955.65
30 mg syringe * 4 Months’ Treatment
$1,611.40 $1,371.53
Tamoxifen
10 mg - 60 tabs
$21.46
$20.92
20 mg - 30 tabs
$20.92
Temozolomide (Temodal®)
5 mg - 5 caps
$48.62
$46.07
20 mg - 5 caps
$169.19
$153.02
100 mg - 5 caps
$785.22
$728.64
250 mg - 5 caps
$1,940.23 $1,798.09
November 27, 2006
Difference
$11.42
7%
$91.70
$128.68
$264.31
15%
20%
$9.28
$18.86
$60.01
$90.23
$25.82
13%
14%
14%
14%
13%
$386.63
$162.74
11%
13%
$21.87
11%
$166.15
$239.87
15%
15%
$0.54
3%
$2.55
$16.17
$56.58
$142.14
5%
10%
7%
7%
Page 25
Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
NS High
NS Low
Medication (Approximate cost per month)
Cost
Cost
Symptom Management Medications
Dexamethasone (Decadron®, generics)
$13.49
$13.44
4 mg - 4 tabs
4 mg - 30 tabs
$34.98
$33.44
Darbepoietin (Aranesp®) 500mcg syringe
$1,541.98 $1,425.99
Epoietin (Eprex®)
10,000 IU syringe
$203.65
$151.74
40,000 IU syringe
$769.01
$622.29
Filgrastim (Neupogen®)
300 mcg – 10 vials
$1,768.49
Metoclopramide (Maxeran®, generics) 10 mg - 30
$12.17
$12.01
tabs
Ondansetron (Zofran®) 8 mg - 4 tab
$120.00
$83.54
Ondansetron (Generic) 8 mg - 4 tab
$84.80
$56.49
Pegfilgrastim (Neulasta®) 6 mg syringe
$2,993.45
Prochlorperazine (Generic) 10 mg - 30 tabs
$14.30
$14.29
Pain Management Medications
Fentanyl Transdermal Patches (Duragesic®)
25 mcg/hr – 5 patches
$59.20
50 mcg/hr – 5 patches
$105.42
75 mcg/hr – 5 patches
$139.50
100 mcg/hr – 5 patches
$181.94
Hydromorphone (Dilaudid®, generics)
1 mg - 30 tabs
$13.30
$13.23
2 mg - 30 tabs
$14.71
$14.67
4 mg - 30 tabs
$17.38
$17.14
8 mg - 30 tabs
$21.55
$21.00
Hydromorphone Sustained Release (Hydromorph Contin®)
3 mg - 60 caps
$56.04
$50.39
6 mg - 60 caps
$79.00
$70.37
12 mg - 60 caps
$129.52
$114.34
18 mg - 60 caps
$187.38
$165.42
24 mg - 60 caps
$235.62
$207.50
30 mg - 60 caps
$279.22
$245.45
November 27, 2006
Difference
$0.05
$1.54
$115.99
4%
8%
$51.91
$146.72
25%
19%
$0.16
$36.46
$28.31
30%
33%
$0.01
$0.07
$0.04
$0.24
$0.55
$5.65
$8.63
$15.18
$21.96
$28.12
$33.77
10%
11%
12%
12%
12%
12%
Page 26
Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
Appendix II. Comparison of Cancer Prescription Costs in Several Canadian Provinces
Medication
Anastrozole (Arimidex®)
1mg - 30 tabs
Bicalutamide (Casodex®)
50 mg - 30 tabs
Bicalutamide (Generic)
50 mg - 30 tabs
Buserelin (Suprefact®)
6.3 mg syringe
Provincial Formulary
(Public Listing, Limited Mark-up)1
Lowest
Ontario
Unit Cost NS Rx
Drug
(Canada) Cost
Quebec
Benefit
Sask
Cancer Treatment Medications
$4.95
$175.56
$163.73
$169.75
$148.50
93%
97%
85%
$6.44
$223.84
$210.66
94%
$4.06
$132.14
No
$140.30
generic
106%
$670.00
$851.17
9.45 mg syringe
$990.00
$1,324.40
Capecitabine (Xeloda®)
150 mg- 28 tabs
$1.83
$73.76
150 mg- 56 tabs
$1.83
$137.40
500 mg- 56 tabs
$6.10
$439.45
500 mg- 84 tabs
$6.10
$651.58
Exemestane (Aromasin®)
25 mg - 30 tabs
Interferon (Intron A ®)
18 MU vial
$4.95
$199.62
$203.94
$235.44
30 MU
$339.90
$382.27
60 MU
$679.80
$796.95
Imatinib (Gleevec ®)
100 mg – 30 tabs
$24.35
$3,477.68
November 27, 2006
$697.80
82%
$1,017.80
77%
$743.40
87%
$1,095.40
83%
$61.60
84%
$115.40
84%
$366.48
83%
$540.20
83%
$163.73
82%
$62.78
85%
$118.84
86%
$382.18
87%
$569.75
87%
$169.77
85%
$221.94
94%
$364.70
95%
$754.20
95%
$2949.80
85%
$230.75
98%
$380.30
99%
$754.20
95%
$3220.44
95%
Page 27
$51.24
69%
Contract Prices,
No Dispensing Fee2
Sask
Cancer
Manitoba Agency
90%
110%
15%
80%
65%
75%
60%
70%
75%
$341.60
78%
80%
80%
$148.50
74%
90%
60%
60%
110%
60%
60%
$2922.00
84%
Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
Medication
Goserelin (Zoladex®)
10.8 mg syringe
Letrozole (Femara®)
2.5mg - 30 tabs
Leuprolide (Eligard®)
22.5 mg syringe
30 mg syringe
Lowest
Unit Cost
$1,087.98
NS Rx
Cost
$1,266.36
$4.95
$205.14
$891.00
$1,121.80
$1,285.20
$1,611.40
Tamoxifen
10 mg - 60 tabs
$0.18
$21.46
20 mg - 30 tabs
$0.35
$20.92
Temozolomide (Temodal®)
5 mg - 5 caps
$7.13
$48.62
20 mg - 5 caps
$28.52
$169.19
100 mg - 5 caps
$142.60
$785.22
250 mg - 5 caps
$356.49
$1,940.23
Provincial Formulary
(Public Listing, Limited Mark-up)1
Ontario
Drug
Quebec
Benefit
Sask
$1,115.80 $1,203.20
88%
95%
$163.73
$169.77
$148.50
80%
83%
72%
Contract Prices,
No Dispensing Fee2
Sask
Cancer
Manitoba Agency
85%
60%
$918.80
82%
$1,313.00
81%
80%
65%
80%
60%
55%
50%
15%
20%
$18.83
88%
$18.83
90%
$45.23
93%
$157.53
93%
$7.80
93%
$1,810.25
93%
$986.52
88%
$1,420.14
88%
$16.92
79%
$16.92
81%
$45.64
94%
$163.38
97%
$790.72
101%
$1,967.12
101%
75%
100%
$35.65
73%
$142.60
84%
$713.00
91%
$1,782.45
92%
115%
115%
115%
1. Percentages are expressed relative to NS cost (e.g. 90% of prescription price in Nova Scotia)
2. Contract prices are confidential; costs are expressed as approximate percentages of Nova Scotia cost, rounded to the nearest 5%
November 27, 2006
Page 28
Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
Medication
Dexamethasone (Decadron®, generics)
4 mg - 4 tabs
4 mg - 30 tabs
Darbepoietin (Aranesp®)
500mcg syringe
Epoietin (Eprex®)
10,000 IU syringe
Provincial Formulary
(Public Listing, Limited Mark-up)1
Ontario
Lowest
NS Rx
Drug
Unit Cost Cost
Quebec
Benefit
Sask
Symptom Management Medications
$0.77
$13.49
$11.02
$9.80
82%
73%
$0.77
$34.98
$31.97
$31.74
91%
91%
$1,340.00 $1,541.98 $1,367.80
80%
$133.95
$203.65
40,000 IU syringe
$401.85
$769.01
Filgrastim (Neupogen®)
300 mcg – 10 vials
$164.57
$1,768.49
480 mcg – 10 vials
$263.32
$1,673.50
95%
$2,661.00
Metoclopramide (Maxeran®, generics) 10 mg - 30 tabs
$0.06
$12.17
Ondansetron (Zofran®)
8 mg - 4 tab
Ondansetron (Generic)
8 mg - 4 tab
Pegfilgrastim (Neulasta®)
6 mg syringe
Prochlorperazine (Generic)
10 mg - 30 tabs
$18.28
$120.00
$9.64
80%
$84.58
70%
$11.52
$84.80
November 27, 2006
$148.45
73%
$429.65
56%
$14.30
20%
90%
50%
$1,678.80
95%
$8.34
69%
95%
$2,686.00
$10.68
89%
55%
$57.09
67%
$11.86
83%
5%
70%
$2,993.45
$0.13
Contract Prices,
No Dispensing Fee2
Sask
Cancer
Manitoba Agency
$10.68
75%
Page 29
70%
$2,319.56
77%
$13.67
96%
20%
Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
Medication
Provincial Formulary
(Public Listing, Limited Mark-up)1
Ontario
Lowest
NS Rx
Drug
Unit Cost Cost
Quebec
Benefit
Sask
Pain Management Medications
Fentanyl Transdermal Patches (Duragesic®)
25 mcg/hr – 5 patches
$8.50
$59.20
50 mcg/hr – 5 patches
$16.00
$105.42
75 mcg/hr – 5 patches
$22.50
$139.50
100 mcg/hr – 5 patches
$28.00
$181.94
Hydromorphone (Dilaudid®, generics)
1 mg - 30 tabs
$0.10
$13.23
2 mg - 30 tabs
$0.14
$14.71
4 mg - 30 tabs
$0.22
$17.38
8 mg - 30 tabs
$0.35
$21.55
Hydromorphone Sustained Release (Hydromorph Contin®)
3 mg - 60 caps
$0.60
$56.04
6 mg - 60 caps
$0.90
$79.00
12 mg - 60 caps
$1.56
$129.52
18 mg - 60 caps
$2.25
$187.38
24 mg - 60 caps
$2.88
$235.62
30 mg - 60 caps
$3.45
$279.22
November 27, 2006
Contract Prices,
No Dispensing Fee2
Sask
Cancer
Manitoba Agency
$52.43
89%
$91.80
87%
$125.93
90%
$154.80
85%
$53.17
90%
$94.42
90%
$123.16
88%
$160.42
88%
$65.96
111%
$111.31
106%
$150.66
108%
$183.79
101%
25%
$10.82
82%
$12.26
83%
$14.86
85%
$18.91
88%
$9.58
72%
$11.10
75%
$13.81
79%
$18.06
84%
$12.27
93%
$14.21
97%
$17.69
102%
$23.41
107%
25%
$45.60
81%
$64.50
82%
$106.08
82%
$149.55
80%
$189.24
80%
$225.15
81%
$46.02
82%
$65.82
83%
$109.38
84%
$154.92
83%
$196.40
83%
$234.12
84%
$55.23
99%
$75.59
96%
$120.38
93%
$167.20
89%
$209.97
89%
$248.64
89%
65%
Page 30
30%
30%
35%
30%
45%
55%
70%
90%
90%
90%
80%
Medication Costs for Nova Scotia Cancer Patients:
Report by the Cancer Medication Costs Working Group, Cancer Care Nova Scotia
November 27, 2006
Page 31