Catastrophic Drug Coverage for New Brunswick. A proposal by the Multiple Sclerosis Society of Canada, Atlantic Division

Transcription

1 Catastrophic Drug Coverage for New Brunswick A proposal by the Multiple Sclerosis Society of Canada, Atlantic Division July 2010

2 Proposal for a Catastrophic Drug Program in New Brunswick i Executive Summary The MS Society, Atlantic Division strongly urges the Government of New Brunswick to implement a universal program of catastrophic drug coverage as soon as possible. Implementing such a program would meet New Brunswickers expectations that medically necessary drugs are accessible without undue financial hardship, and will fulfil commitments made by the government since 2004 and as recently as June Currently 28 per cent of New Brunswickers lack insurance for these costs and the number of families currently paying more than five per cent of its net household income on prescription drugs is 68 per cent higher than the rest of Canada. A catastrophic drug program would mean that working families who need expensive drug treatments will be able to continue to be employed. In doing so, they will avoid resorting to social assistance programs simply to obtain coverage, thereby becoming dependent on the state for their incomes (in addition to their drugs) over their lifetimes. Families without insurance or with employer-sponsored health benefits who must pay thousands of dollars in co-payments will not have to make difficult choices between the necessities of life and drug treatments. Finally, workers who lose their jobs will not be vulnerable to unexpected and crippling costs. Because patients will be able to afford to take their medications as prescribed, New Brunswick s health system will be relieved of many unnecessary ER and physician visits. MS patients are particularly vulnerable to the high costs of drugs which are needed to treat the primary disease, to manage its symptoms and to treat other, unrelated conditions. Although Plan H of the New Brunswick Prescription Drug Program provides partial coverage for disease-modifying therapies, MS patients are required to pay a large part of these costs, in addition to covering the entire cost of their other drug treatments. These out-of-pocket expenses are often unmanageable. Because MS most often strikes in the prime of life, drugs which delay the progression of disease enable patients to continue to fulfil their roles as employees, parents and contributing members of society. The need for drug coverage should not determine when an MS patient leaves or rejoins the workforce, force patients to spend their family s savings, or exhaust their personal assets. These policies serve the interests of neither patients nor the Government of New Brunswick. New Brunswick is one of only two provinces in Canada that lacks a catastrophic drug coverage program. Other Atlantic provinces have made steps in this direction which, although far from ideal, provide at least some relief to their residents. The MS Society recommends a program which is based on the principles of universality, affordability, equity and public administration. We propose that no family pays more than five per cent of its net household income on prescription drugs, and that families below the Low Income Cut-Off are exempted from contributions. The range of drugs covered and the time period for review must be aligned with the practices of other provinces and the government of New Brunswick should set minimum standards of coverage by private insurance to ensure equity across the province. The cost to the government, estimated at between $20 and $40 million, would be offset in part by savings in social assistance payments, health care expenses, increased income taxes and improved economic productivity. Large expected savings from the patent expiries of major drug categories can be redirected to expand coverage. Moreover, the people of New Brunswick expect this support from each other and from their government. The MS Society offers its assistance to make catastrophic drug coverage a reality.

3 Proposal for a Catastrophic Drug Program in New Brunswick 1 Contents Executive Summary i 1. What is Catastrophic Drug Coverage? 1 2. Why Do New Brunswickers Need a Catastrophic Drug Plan? 2 3. Costs and Benefits of Drugs for MS Patients 5 4. Models of Catastrophic Drug Coverage 6 5. Proposed Catastrophic Drug Coverage Model for New Brunswick Costs and Sources of Funding Conclusions 13 Appendix 1 New Brunswick Prescription Drug Program: eligibility and costs What is Catastrophic Drug Coverage? The term catastrophic refers to costs of drugs that are high relative to families incomes. Today, it is not unusual for patients to have drug costs of more than $5,000 a year. Multiple drugs required to manage chronic diseases can reach thousands of dollars a year even though they each cost only a few dollars a day. Individual therapies for multiple sclerosis, arthritis or cancer can now cost between $20,000 and $130,000 a year. Many people who have private insurance must pay a contribution of 20 per cent or more and find these expenses difficult to manage. For people without any insurance coverage, the costs are devastating. Catastrophic drug costs are commonly defined as drug expenses amounting to more than a certain percentage of net family income. Three per cent is the level used by Revenue Canada for income tax deduction of medical expenses and was the threshold set by the Kirby Commission. 1 The present MS Society proposal recommends a five per cent limit, based on the lowest level used by the Newfoundland & Labrador Prescription Drug Program. 1 Standing Senate Committee on Social Affairs, Science and Technology, 2002

4 Proposal for a Catastrophic Drug Program in New Brunswick 2 2. Why Do New Brunswickers Need a Catastrophic Drug Plan? The people of New Brunswick need a system of catastrophic drug coverage because the costs of many drugs, including treatments for multiple sclerosis, have grown beyond the financial reach of individual families. Although funds were made available to the provinces to address this issue (among others) in the Health Accords of 2003 and 2004, New Brunswick is one of only two remaining provinces without a universal plan for high cost drugs. (The other province, Prince Edward Island, covers high cost drugs for many of its residents.) The lack of access to affordable prescription drug insurance for all New Brunswickers undermines the principles of universality and accessibility on which the Canada Health Act is based. Although the Act does not require provinces to cover drugs administered outside hospitals, these have increasingly become "medically necessary". Canadians expect their public systems of drug coverage to adhere to the same principles as the other medically necessary services defined under the Act. The issue of coverage for high cost drugs affects most New Brunswickers. Three-quarters of households in this province purchase prescription drugs, with an average annual expenditure of $ As new, highcost drugs are introduced every year, this situation will increase in importance over time. How many New Brunswickers are vulnerable to catastrophic drug costs? The proportion of New Brunswick families paying over five per cent of their net household income on prescription drugs is 68 per cent greater than for Canada as a whole, as shown in the table below. Table 1: Percentage of families with high drug costs relative to income Geography Spending category 2006 Canada Spending on prescription drugs greater than 3% of after tax income 8.0 Spending on prescription drugs greater than 5% of after tax income 3.8 Spending on prescription drugs greater than 3% of New after tax income 11.1 Brunswick Spending on prescription drugs greater than 5% of after tax income 6.4 Source: Statistics Canada Table Household spending on prescription drugs as a percentage of after-tax income, Canada and provinces, annual The root cause of this vulnerability is the lack of adequate prescription drug insurance. It is estimated that 28 per cent of New Brunswickers, or approximately 200,000 residents of the province, do not have any coverage. 3 2 Statistics Canada, 2008 figures 3 Applied Management Consultants. PRISM database, 2008

5 Proposal for a Catastrophic Drug Program in New Brunswick 3 Which New Brunswickers are at risk? The following groups of people in New Brunswick are most likely to face significant financial hardship due to high cost drugs. Group 1: Families with no insurance coverage One-third of working-age families and 18 per cent of senior families have no insurance Low-income workers who have no insurance through work are not eligible for NBPDP; most do not want to give up their family s assets in order to qualify for social assistance Persons diagnosed with a medical condition are uninsurable as individuals Group 2: Families with private insurance coverage Fifty-eight per cent of working-age families and 27 per cent of senior families have private insurance Three-quarters of insurance plans require a copayment most commonly 20 per cent for each prescription One in six private insurance plans has an annual or lifetime cap on claims which may be lower than the cost of many newer drugs Employees who are laid off lose their drug plans along with their jobs Group 3: Seniors and MS patients with provincial government coverage The NBPDP provides coverage for 47 per cent of NB senior families; 15 per cent of these families may have out-of-pocket costs greater than 5 per cent of their income Although Plan H provides some assistance to MS patients, the required contributions often exceed the accepted five per cent of net household income Source: Applied Management Consultants, Coverage of MS patients in New Brunswick Multiple sclerosis patients in New Brunswick are eligible for coverage of disease-modifying therapies under Plan H of the New Brunswick Prescription Drug Program (NBPDP). Individuals on this plan pay an annual registration fee of $50 and are required to pay a percentage of the drug cost for each prescription based on discretionary income. Families having discretionary income (including savings) of over $100,000 do not qualify. There are several important concerns with Plan H. 1. Liquid assets over $5,000 are included in the calculation of discretionary income, therefore families savings often must be spent before assistance is provided; 2. The degree of coverage is insufficient. Families with discretionary incomes over $17,000 but under $100,000 must pay between 35 and 76 per cent of the cost of drugs, which amounts to $7,000 to $15,200 a year for an average disease-modifying MS therapy. This is far in excess of the five per cent threshold defining catastrophic drugs costs; 3. Drugs needed by MS patients to manage symptoms of their disease (such as pain, spasticity and fatigue) or for other, unrelated diseases are not covered under Plan H.

6 Proposal for a Catastrophic Drug Program in New Brunswick 4 Case Study: Martha Jones Martha Jones (not her real name) is a Moncton widow whose daughter will be attending university this fall. Martha s income, from a disability pension, is less than $20,000 annually. Her daughter s part-time job yields $4,000 to $5,000 a year. Martha is eligible for drug coverage under her deceased husband s health benefits plan, which covers 80 per cent of drug expenses. One of these drugs, Copaxone, is a disease-modifying MS treatment which has enabled her to continue living in her home. Martha s monthly out-of-pocket drug expenses are $321 for Copaxone and approximately $80 for other drugs, for a total of $400, or 20 per cent of the family s before-tax income. This expense is proving unmanageable. As an MS patient, Martha qualifies for Plan H, however the small life insurance payout she received upon her husband s death disqualifies her from eligibility based on income. Martha has been advised to spend the insurance payout but she does not want to do so because the funds were intended to help provide for the family s future, including her daughter s education. In February, Martha and her neurologist decided she would stop taking Copaxone since it was becoming too expensive. Within ten days she was hospitalized and so resumed her treatments. She is using her credit cards to cover the costs and is short of money each month. Due to their disease, many MS patients fall into the categories of New Brunswickers who are vulnerable to unaffordable drug costs, as described above: once diagnosed, MS patients are uninsurable as individuals many are unable to work, and lose private insurance coverage with their jobs some must live on disability payments, which are lost if they return to work where they may be eligible for group coverage most are unable to afford co-payments (usually 20 per cent for private plans) which amount to thousands of dollars a year for disease-modifying therapies, or may be subjected to annual caps Often in these situations, MS patients are forced to resort to social assistance to cover the costs of needed medications. To become eligible for this support, they must first exhaust their personal assets. In doing so, they deprive themselves and their families of their homes, savings and investments in future education and retirement. Because the drugs required by one person are unaffordable, the entire family becomes dependent on government support for their lifetimes. Future trends The need for catastrophic drug coverage has become urgent as a wave of new and expensive targeted therapies is putting growing pressure on drug budgets across the country. Biotechnology and oncology drugs especially are growing two to three times as fast as overall drug costs 4 and this trend is expected to accelerate in the future. 4 IMS Health, 2008

7 Proposal for a Catastrophic Drug Program in New Brunswick 5 3. Costs and Benefits of Drugs for MS Patients The economic consequences of MS are significant, especially since the disease generally strikes earlier in life. Although the majority of individuals with MS are employed at the time of diagnosis, approximately half leave their jobs within a decade. 5 Productivity losses in Canadian studies were measured at $11,670 to $21,720 annually per patient, depending on disease severity. 6 Progressive disability in MS also has an associated economic burden to society in general. This includes the costs of inpatient admissions, ambulatory visits, informal care and short-term sick leave, all of which more than double as the disease progresses. 7 Disease-modifying drugs Disease-modifying drugs to treat multiple sclerosis cost between $15,800 and $31,000 a year. As the name suggests, this class of drugs can alter the course of this debilitating disease and has made an enormous difference in the lives of many MS patients. Drugs in this class have been proven to delay the onset of disability, allowing patients to return to a productive life as employees, parents, family members and contributors to society. The Dalhousie Multiple Sclerosis Research Unit (DMSRU) has a publicly funded program that provides disease-modifying drugs to all eligible MS patients in Nova Scotia free of charge. A study of DMSRU patients showed that this program was effective in slowing the progression of neurologic disability. The risk of reaching high levels of disability was reduced for the clinic population as a whole and was delayed by approximately four years. 8 Symptom-management drugs For approximately 80 per cent of MS patients, the disease progresses from an episodic disorder to a more progressive state. As disability progresses, patients experience increasing pain, spasticity and fatigue and withdraw from active life. Drugs are needed not only to slow the progression of disease but also to manage these symptoms. As mentioned earlier, many MS patients also need drugs to treat unrelated chronic conditions (such as diabetes). Multiple prescriptions each costing two to three dollars a day can easily add up to thousands of dollars a year. 5 Naci H et al. Economic Burden of Multiple Sclerosis. A Systematic Review of the Literature. Pharmacoeconomics 2010; 28 (5): Grima T et al. Cost and health related quality of life consequences of multiple sclerosis. Multiple Sclerosis (2000) 6, Naci H et al. Economic Burden of Multiple Sclerosis. A Systematic Review of the Literature. Pharmacoeconomics 2010; 28 (5): Veugelers PJ et al. Disease progression among multiple sclerosis patients before and during a disease-modifying drug program: a longitudinal population-based evaluation. Multiple Sclerosis 15(11) , 2009

8 Proposal for a Catastrophic Drug Program in New Brunswick 6 4. Models of Catastrophic Drug Coverage All provinces except New Brunswick and Prince Edward Island have implemented universal prescription drug programs that cover their residents for high drug costs relative to income. The other Atlantic Provinces were the latest to do so and, in general, their programs place a much higher financial burden on families compared with the other provinces. How do other Atlantic provinces provide catastrophic coverage? Many families in Atlantic Canada pay more than five per cent of net household income for drug coverage under the public drug programs. Newfoundland & Labrador The Assurance Plan of the Newfoundland & Labrador Prescription Drug Program (NLPDP) provides assistance for all families in the province for its list of covered drugs. The amount the family must pay is based on income, as shown in the table below. Families with net incomes $150,000 or greater are not covered. Table 2 NLPDP Assurance Plan income-based deductible Net Household Income Maximum % Income Paid for Eligible Drugs up to $39,999 5% $40,000 up to $74, % $75,000 up to $149,999 10% Nova Scotia Nova Scotia Family Pharmacare provides income-based coverage of eligible drugs, calculated on the basis of gross family income, less amounts for dependants. The calculation of the patient's contribution is based on the formula in the table below. Table 3 Calculation of patient contributions for Nova Scotia Family Pharmacare Type of Contribution Level Maximum Contribution Co-payment 20% of the prescription cost Income-based maximum copayment amount Deductible The remaining 80% of the prescription cost goes towards the income-based Income-based maximum deductible amount deductible. Total contributions Once the maximum deductible amount is reached, the patient pays only the 20% co-payment to an income-based total maximum amount. Once this maximum is reached, the government pays 100% of the costs of the prescription. Income-based total amount

9 Proposal for a Catastrophic Drug Program in New Brunswick 7 The three examples of out-of-pocket expenses in the table below were provided by the Nova Scotia government. Unlike other provinces, payments are calculated based on gross family income, so the percentage of net income paid would be greater than the figures shown here. Table 4 Examples of out-of-pocket expenses under Nova Scotia Family Pharmacare Family Income (gross) Number of family members Drug cost (annual) Out-of-pocket expense Percentage of gross income $25,000 4 $1,000 $ % $40,000 2 $5,050 $ % $81,000 4 $30,000 $14, % As mentioned in the previous section, the Dalhousie Multiple Sclerosis Research Unit (DMSRU) provides disease-modifying drugs free of charge to all eligible MS patients in the province in a separate program to Pharmacare. Prince Edward Island Prince Edward Island does not have a universal program, but has 31 different drug programs which cover various populations and specific drugs. Low income families with children are eligible for Family Health Benefits which include assistance with drug costs. The province's five High Cost Drug Programs provide income-based assistance for the costs of specific drugs and diseases for families with annual net incomes under $150,000. A sliding scale is applied to the net household income, adjusted for the number of dependent children. The amount of assistance ranges from zero to 100 per cent of the cost of drugs. Beneficiaries must pay the pharmacy dispensing fee. New Brunswick New Brunswick does not have a universal program for prescription drug coverage and has the smallest proportion of the population covered by its public drug programs compared to the other Atlantic Provinces. Appendix 1 shows the ten programs available under the New Brunswick Prescription Drug Program (NBPDP). General populations covered under the NBPDP are: seniors who are eligible to receive the Guaranteed Income Supplement (GIS), residents of nursing homes, and social assistance recipients (including temporary drug card-only benefits). In December 2009, the latter plan was extended to cover drug costs for social assistance recipients up to 12 months after they find a job. Other NBPDP plans cover specific drugs. Groups not covered under the NBPDP include: Seniors not eligible for GIS payments (persons over age 65 may purchase the provincial drug plan through Medavie Blue Cross for a premium of $105 per month); Working families of all income levels. MS patients are partially covered for the costs of their disease-modifying drugs under Plan H, as described in the previous section.

10 Proposal for a Catastrophic Drug Program in New Brunswick 8 How do the Atlantic programs compare regarding assistance with high drug costs? The following table shows a comparison of eligibility for coverage of high drug costs and of out-ofpocket expenses among the provincial plans in Atlantic Canada for families under age 65 having average and low incomes. The comparison is from the perspective of a working-age MS patient who incurs a $20,000 drug expense for disease-modifying drugs and/or drugs for symptom management. Prov. NL NS PE NB Table 5: Comparison of coverage and out-of-pocket expenses for high-cost drugs in Atlantic Canada Universal Eligibility? Yes Yes No No Drug Program Assurance Plan Family Pharmacare DMSRU (diseasemodifying) High Cost Drugs* Cost Burden of a $20,000 Annual Drug Expense Without Private Insurance Family with Average Income (net $50,600) $ % Net income Family with Low Income (net $22,700) % Net $ income $3, % $1, % $8, % $1, % $0 0% $0 0% $2, % None $20, % Plan H** no assets Plan H with $27,500 assets None approx. $30 approx. $30 0.1% 0.1% $9, % $ % $20, % $6, % $20, % $20,000 88% With Private Insurance Family with Average Income (net $50,600) $ % Net income $4, % Sources: NLPDP website; NS Family Pharmacare calculator (on website) with confirmation by telephone; PEI figures confirmed by drug plan assessors; NB figures from regulations to the Prescription Drug Payment Act. * Several High Cost Drugs Programs in PEI cover drugs required to treat specific diseases (MS, pulmonary hypertension, Remicade/Enbrel, diabetes, cancer). For drugs outside these categories (including symptommanagement drugs for MS patients) the average-income family is not eligible for assistance. The low-income family would be covered for all prescribed drugs included on the PEI formulary under Family Health Benefits because they have dependent children under age 18 and their income is below the established threshold. ** Plan H covers disease-modifying drugs to treat MS. It does not cover symptom-management drugs. Liquid assets over $5,000 are included in the calculation of the patient s contribution; average-income families with more than $27,500 in liquid assets would pay the full $20,000 drug cost. A $50 annual registration fee is also applied.

11 Proposal for a Catastrophic Drug Program in New Brunswick 9 Notes to table: Family is defined as two adults and two children (3 dependants). Average after-tax household income for New Brunswick families of two or more is $50,600 (Statistics Canada 2007). Low income is defined as $22,700 (net), based on the 2008 Statistics Canada Low-Income Cut-Off (LICO) for Canadian families living in rural areas. (Provincial LICO was unavailable.) Since Nova Scotia Family Pharmacare contributions are based on gross household income, net income was calculated using tax rates of 25% and 10%, respectively, for the average and low family incomes to estimate gross income ($67,500 and $25,200). Private insurance costs are based on a 20 per cent co-payment and no deductible amount.

12 Proposal for a Catastrophic Drug Program in New Brunswick Proposed Catastrophic Drug Coverage Model for New Brunswick The New Brunswick government has committed to providing universal coverage for catastrophic drug costs since ,10 Most recently (June 2010) the Minister of Social Services clarified that catastrophic coverage would be part of a universal drug coverage plan to be introduced by We recommend that the following criteria should apply to this program. Principles The catastrophic drug coverage program should be based on the following principles: Universal Affordable Equitable Publicly administered Features The proposed program would have the following features: Includes all residents of New Brunswick regardless of age, health status, employment status or income level Beneficiaries must not be required to pay more than five per cent of their net family income (adjusted for personal deductions and using the Low Income Cut Off as a threshold below which no contributions are required). The program must be equitable with coverage provided to other Canadians: It must cover an acceptable range of drugs and must approve new drugs within a similar review period. The government must set minimum standards for private insurers, based on the public program, for eligibility, affordability and comprehensiveness of their formularies. 9 Healthy Futures: Securing New Brunswick s Health Care System. The Provincial Health Plan Bruce Bartlett; Advocate pushes for catastrophic drug plan in N.B.; Telegraph-Journal, March 13th, Benjamin Shingler; Catastrophic drugs will be part of drug plan: Lamrock; Telegraph-Journal, June 18th, 2010

13 Proposal for a Catastrophic Drug Program in New Brunswick Costs and Sources of Funding An estimation of the costs of a universal catastrophic drug program must take into account the incremental tax dollars needed to provide additional coverage, balanced against costs saved or revenues gained by more efficient use of the health system and improved health outcomes. Estimating these amounts will require more detailed calculations than are possible here. The paragraphs below describe the categories of potential costs and savings that may be considered. Costs to New Brunswick of not having universal catastrophic drug coverage The lack of a catastrophic drug coverage program is resulting in costs to government departments, employers and families which may not be visible but are certainly significant. Higher utilization of medical services such as physician appointments, emergency room visits and hospitalizations have been demonstrated by numerous studies from Canada and the U.S. when patients cut back or forgo their medications due to unaffordability. 12,13,14 As was shown in the previous sections, treatment with disease-modifying drugs enables many MS patients to continue to fulfill their roles in society, including returning to work. The province benefits because economic productivity is increased, there is less reliance on social assistance and income taxes are collected. These outcomes also apply to other serious diseases for which high-cost drug therapies are used. Cost estimates of catastrophic drug coverage Other groups have estimated the costs to the government of implementing a universal program to cover high drug costs relative to income. Limiting families' contributions to five per cent of net household income would cost the New Brunswick government approximately $44 million annually, or $53 per resident. 15 (A second source pegged the cost of catastrophic drug coverage at approximately $20 million, but did not reveal the basis of its calculation. 16 ) Sources of funding There is an opportunity for New Brunswick to benefit from the impending "patent cliff" which will result, over the next few years, in the availability of cheaper generic versions of many drugs that presently account for the government's highest expenditures. Adopting the approaches of other provinces (notably Ontario) to reduce the allowable price of generic drugs will enable the government of New Brunswick to reallocate these cost savings toward extending NBPDP eligibility to residents who currently lack drug coverage. Another additional approach is to allow all uninsured residents to purchase the NBPDP plan, as seniors are allowed to do, for a reasonable premium and without discrimination due to age or health status. 12 Goldman DP et al.; Prescription Drug Cost Sharing. Associations With Medication and Medical Utilization and Spending and Health; JAMA. 2007;298: Tamblyn R et al. Adverse events associated with prescription drug cost-sharing among poor and elderly persons. JAMA Jan 24-31; 285(4): Ungar W et al. Effect of Cost-Sharing on Use of Asthma Medication in Children. Arch Pediatr Adolesc Med. 2008;162(2): Applied Management Consultants. Statistics presented to New Brunswick government representatives November This figure was confirmed by then-health Minister Mike Murphy as being close to the government s calculations. 16 Benjamin Shingler; Catastrophic drugs will be part of drug plan: Lamrock; Telegraph-Journal, June 18th, 2010.

14 Proposal for a Catastrophic Drug Program in New Brunswick 12 These residents would then be funding their own protection. Families who are unable to afford the premiums would be able to rely on the government's catastrophic drug program which would protect them only against costs greater than five per cent of net adjusted household income.

15 Proposal for a Catastrophic Drug Program in New Brunswick Conclusions In summary, the MS Society recommends the immediate implementation of a program of catastrophic drug coverage that is universal, affordable, equitable and publicly administered. No family should have to pay more than five per cent of its net income on prescription drugs. The program should cover an acceptable range of drugs and both the formulary and approval timelines should be benchmarked to the practices of other provinces. In addition, the government should set minimum standards for private insurers for eligibility, affordability and comprehensiveness of their formularies, based on those of the public program. A program of catastrophic drug coverage in New Brunswick would, at a reasonable cost, protect the over 200,000 residents of the province who are vulnerable to the potentially devastating consequences of high drug expenditures, allowing many to receive drug treatments that will allow them to return to productive lives as contributing members of society. Moreover, such a program would reinforce the principles of universality and accessibility that New Brunswickers expect from their health system.

16 Proposal for a Catastrophic Drug Program in New Brunswick 14 Appendix 1 New Brunswick Prescription Drug Program: eligibility and costs Beneficiary groups covered by provincial programs: A (Seniors) B (Cystic Fibrosis) E (Adults in Licensed Residential Facilities) F (Social Development) G (Special needs children and children in care of the Minister of Social Development) H (Multiple Sclerosis) R (Organ Transplant) T (Human Growth Hormone Deficiency) U (HIV/AIDS) V (Nursing Home Residents) The New Brunswick Prescription Drug Program Formulary lists the drugs which are eligible for coverage for each plan. NBPDP Plan Eligibility Costs Gaps Plan H (Multiple Sclerosis) Individuals diagnosed with Multiple Sclerosis and who have a prescription written by a neurologist for the drug Avonex, Rebif, Betaseron, Copaxone or Tysabri. Individuals on this plan pay an annual registration fee of $50 and are required to pay a percentage of the drug cost for each prescription ranging from zero to 100 per cent (co-pay). The copay amount will be determined during the application process and is based on discretionary income. No coverage for drugs to manage MS symptoms (pain, fatigue, spasticity). Copayments unacceptably high. Discretionary income includes family s savings. Plan A (Seniors) Persons 65 years of age or older who: Receive the Federal Guaranteed Income Supplement (GIS) OR Qualify based on an annual income as follows: - a single person with an annual income of $17,198 or less; - couple with both persons 65 years of age or older, with a Beneficiaries receiving the GIS are required to pay a co-payment of $9.05 for each prescription, up to a maximum of $250 in one calendar year. Beneficiaries who qualify based on their total annual income are required to pay a copayment of $15.00 per prescription with no yearly co-payment maximum. Seniors and working families with high drug costs relative to net household income.

17 Proposal for a Catastrophic Drug Program in New Brunswick 15 combined annual income of $26,955 or less; - couple with one person who is under 65 years of age, with a combined annual income of $32,390 or less. Plan E (Adults in Licensed Residential Facilities) Plan F (Social Development Clients) Plan V (Nursing Home Residents) Individuals who reside in a licensed adult residential facility. Eligibility for drug coverage through this plan is determined by the Department of Social Development. Individuals who hold a valid health card issued by the Department of Social Development. Eligibility for drug coverage through this plan is determined by the Department of Social Development. As of December 2009, coverage may be extended up to a year after the client has become employed. Individuals who reside in a registered nursing home. Eligibility for drug coverage through this plan is determined by the Department of Social Development. Individuals on this plan are required to pay a co-payment of $4.00 for each prescription up to a maximum of $250 per person in a fiscal year. Individuals on this plan are required to pay a co-payment of $4.00 for each prescription for adults (18 and over) and $2.00 for children (under 18 years) up to a maximum of $250 per family unit in a fiscal year. There are no copayments or fees associated with this plan.

18 The development of this proposal is supported by Pfizer Canada Inc. through an unrestricted educational grant.