Prescription Drugs Payment of Benefits Regulation

Prescription Drugs Payment of Benefits Regulation, M.R. 60/96 The Prescription Drugs Cost Assistance Act , C.C.S.M. c. P115 Regulation 60/96 Registered March 22, 1996 bilingual version (HTML) Table of Contents Section PART 1 INTRODUCTORY PROVISIONS 1 Definitions 1.1 Professional fee 1.2 General requirements PART 2 BENEFITS FOR SPECIFIED DRUGS 1.3 Application 2 Persons eligible for benefits 3 Determination of family unit 4 Individual may be a family unit 5 Amount of benefits 5.1 Diabetes control supplies are included in cost of specified drugs 5.2 Repealed 6 Deductible amount 7 Election if income changes PART 3 DRUGS PROVIDED AT NO COST 7.1 Eligible persons 7.2 Benefits 7.3 Benefits are cost of specified drugs PART 4 GENERAL PROVISIONS 8 Benefits subject to conditions 9 Use of electronic data storage system in determining Part 2 benefits 9.1 Determining Part 3 benefits 9.2 Minister to pay pharmacist 10 Transitional 10.1 Transitional: portion of 2003 benefit year 11 Repeal 12 Coming into force Schedule PART 1 INTRODUCTORY PROVISIONS Definitions 1 In this regulation, "Act" means The Prescription Drugs Cost Assistance Act ; («  Loi  ») "applicant" means an eligible person who applies for benefits under the Act; (« demandeur ») "benefit year" means the year beginning on April 1 and ending on March 31 of the next year; (« année d'indemnisation ») "cost of specified drug" means (a) for a specified drug purchased in Manitoba, an amount not more than the price of the drug to the pharmacist or holder of the pharmacy licence plus a professional fee permitted by section 1.1, and (b) for a specified drug purchased in another province or territory of Canada, the cost incurred to a maximum amount the minister considers reasonable; (« coût d'un médicament couvert ») "electronic data storage system" means the computerized electronic information storage system maintained by the minister for the purposes of the Act and this regulation; (« système de stockage électronique des données ») "eligible dependant" means a person under 18 years of age who is a child of an eligible person; (« personne à charge admissible ») "extemporaneous" , in relation to the preparation of a specified drug, means the mixing together of ingredients in accordance with a prescription to provide a customized drug formula without duplicating a commercially-available product, but does not include reconstituting a drug with only water; (« préparer extemporanément ») "price of specified drug" means (a) in the case of a specified drug designated in the formulary established under The Pharmaceutical Act , the cost for the lowest priced interchangeable product specified in the formulary, whether or not the specified drug is prescribed with a "no sub" or "no substitution" instruction, and (b) in any other case, the lowest usual price of the specified drug as charged from time to time by wholesalers or manufacturers that supply pharmaceuticals to pharmacists or holders of pharmacy licenses; (« prix d'un médicament couvert ») "taxation year" means the calendar year beginning on January 1 and ending on December 31. (« année d'imposition ») M.R. 141/2000 ; 1/2004 ; 82/2005 ; 53/2012 ; 180/2014 ; 77/2017 ; 96/2021 ; 27/2023 ; 35/2024 Professional fee 1.1 For the purpose of the definition "cost of specified drug" in section 1, a professional fee may not exceed the amount determined in accordance with the following rules: 1. Unless a specified drug is prepared extemporaneously, the professional fee may not exceed the lesser of (a) $30 or, in the case of a specified drug for which a benefit is payable under Part 3, $14; and (b) the amount regularly charged by the pharmacist to persons responsible for paying the professional fee without reimbursement. 2. If a specified drug is prepared extemporaneously, the professional fee may not exceed the greater of (a) the amount payable under item 1; and (b) the amount determined by multiplying the number of minutes spent on the preparation (determined in accordance with guidelines approved by the minister) by (i) $1 in the case of a non-sterile preparation, to a maximum of $30, or (ii) $2 in the case of a sterile preparation, to a maximum of $60. 3. If a specified drug belongs to a class of specified drugs designated by the minister, no more than two professional fees are payable for the supply of that drug in a 30-day period, even if (a) the prescription for the drug specifies that the drug is to be dispensed in more than two intervals in the 30-day period; or (b) more than two prescriptions are issued for the drug in the 30-day period. However, the minister may approve payment of an additional professional fee or fees in special circumstances. 4. Subject to rule 5, if a specified drug for which a benefit is payable under Part 3 belongs to a class of specified drugs designated by the minister, not more than one professional fee is payable for the supply of the drug in a 30-day period, even if (a) the prescription for the drug specifies that the drug is to be dispensed in more than one interval in the 30-day period; or (b) more than one prescription is issued for the drug in the 30-day period. However, the minister may approve payment of an additional professional fee or fees in special circumstances. 5. If a specified drug is an oral contraceptive for which a benefit is payable under Part 3, other than an emergency oral contraceptive, not more than one professional fee is payable for the supply of the drug in a 90-day period, even if (a) the prescription for the drug specifies that the drug is to be dispensed in more than one interval in the 90-day period; or (b) more than one prescription is issued for the drug in the 90-day period. However, the minister may approve payment of an additional professional fee or fees in special circumstances. 6. The professional fee provided for in this section applies to all packaging formats, including a blister pack. M.R. 77/2017 ; 35/2024 ; 84/2024 General requirements 1.2(1) Benefits are payable in respect of a specified drug under this regulation if the drug is ordered for its approved medical indications for an eligible person and, except in the circumstances mentioned in section 5.1, prescribed by a physician, licensed dentist, pharmacist, midwife, optometrist, podiatrist, registered nurse or registered psychiatric nurse. 1.2(2) Despite subsection (1), benefits are not payable in respect of an extemporaneous preparation unless the main therapeutic ingredient in the preparation is specified by the minister as a drug in respect of which benefits may be paid. M.R. 35/2024 ; 84/2024 PART 2 BENEFITS FOR SPECIFIED DRUGS APPLICATION Application of this Part 1.3 This Part applies in respect of benefits for specified drugs other than benefits under Part 3. M.R. 35/2024 ELIGIBLE PERSONS Persons eligible for benefits 2(1) Persons who meet the following qualifications are designated as an eligible class of persons entitled to receive benefits under this Part: (a) a person must be a resident as defined in The Health Services Insurance Act and be registered and eligible for benefits under that Act; (b) a person must be a member of a family unit whose members have, in a benefit year, collectively spent more on specified drugs than the deductible amount determined under section 6; (c) an application to become eligible must be made to the minister by the person's family unit, and the minister must be satisfied that the members of the family unit have, in a benefit year, collectively spent more on specified drugs than the deductible amount determined under section 6. 2(2) In determining whether members of a family unit have spent more on the cost of specified drugs than the deductible amount determined under section 6, a person is not considered to have spent an amount on the cost of a specified drug in the following cases: (a) [repealed] M.R. 164/2009 ; (b) the person is entitled to have the cost of the specified drug paid by (i) the government, if the payment is not made under the authority of the Act, (i.1) the government, if the payment is made under Part 3, (ii) the Government of Canada, (iii) the government of another jurisdiction in Canada or elsewhere, including, without limitation, a municipal government in Manitoba, or (iv) an agent or agency of a government described in any of subclauses (i) to (iii); (c) the person has at any time purchased or used the specified drug in breach of the Food and Drugs Act (Canada), the Controlled Drugs and Substances Act (Canada) or The Pharmaceutical Act ; (d) the minister waives the deductible amount for that specified drug pursuant to subsection 5(2). M.R. 141/2000 ; 164/2009 ; 35/2024 Determination of family unit 3(1) For the purpose of this regulation, members of a family unit are: (a) an individual; (b) his or her spouse, if any; (c) any child of the individual or his or her spouse who is under 18 years of age. 3(2) A person is a spouse of another if (a) they are married; or (b) they are in a conjugal relationship outside marriage and have been in that relationship throughout the 12 months preceding the date an application for benefits is made. M.R. 1/2004 Individual may be a family unit 4 An individual who is the only member of a family unit constitutes a family unit for the purpose of this regulation. BENEFITS Amount of benefits 5(1) For each benefit year beginning on or after April 1, 1996, the amount of the benefits payable to a family unit is the cost of specified drugs incurred collectively by the family unit in the benefit year that exceeds the deductible amount determined under section 6. 5(2) Despite subsection (1), the minister may waive the deductible amount in relation to (a) specified drugs purchased for a member of a family unit who is receiving palliative care in his or her home; or (b) specified drugs, as determined by the minister, purchased for a member of a family unit who is being treated for cancer, on an out-patient basis, by CancerCare Manitoba. M.R. 141/2000 ; 56/2012 Diabetes control supplies are included in cost of specified drugs 5.1 Syringes, needles and glucose test strips are included in the cost of specified drugs under section 5, but do not require a prescription, if the pharmacist is satisfied they are required by an eligible person (a) for monitoring his or her diabetes; or (b) who is using insulin for the control of diabetes. M.R. 141/2000 5.2 [Repealed] M.R. 82/2005 ; 53/2012 ; 96/2021 ; 84/2024 Deductible amount 6(1) The deductible amount for a benefit year is the greater of (a) $100.; and (b) the amount determined by the formula A × B where A is the amount determined by the following formula, rounded down to the nearest dollar: C − ((D + E) × $3,000.) where C is the total annual income of the applicant and the applicant's spouse for the relevant taxation year, D is 1 if the applicant has a spouse and 0 in any other case, E is the number of the applicant's eligible dependants; B is the deductible rate set out opposite the amount of A in the Schedule. 6(2) A person's relevant taxation year is the person's taxation year that ended immediately before the beginning of the benefit year just ended, except when he or she has made an election under section 7. 6(3) A person's annual income is (A or B) − C where A is all income from any source as entered on line 150 of the person's Notice of Assessment issued under the Income Tax Act (Canada) for the relevant taxation year; B is the person's income, as determined under subsection (4), if a Notice of Assessment for the relevant taxation year is not available; C is any deductions approved by the minister. 6(4) If a Notice of Assessment for the applicant or the applicant's spouse is not available in a relevant taxation year, (a) the person whose Notice of Assessment is unavailable shall provide to the minister (i) the Notice of Assessment for the taxation year preceding the relevant taxation year, if it is available, and (ii) any other records and information the minister requires concerning the person's income for the relevant taxation year; and (b) the minister shall, from the material so provided, determine the person's income for the relevant taxation year. M.R. 141/2000 ; 98/2002 ; 107/2003 ; 61/2004 ; 42/2005 ; 66/2006 ; 78/2008 ; 90/2009 ; 84/2024 Election if income changes 7(1) Subject to subsection (5), an applicant, or if an applicant has a spouse, the applicant and his or her spouse, may elect to have their annual income determined under subsection (2), if, as a result of the election, their annual income is at least 10% less than it would be if no election were made. 7(2) The annual income of an applicant, or an applicant and his or her spouse, who makes an election under subsection (1) shall be determined (a) in accordance with subsections 6(3) and (4), but on the basis that their relevant taxation year is the taxation year in which the benefit year began; or (b) if the taxation year in which the benefit year began has not ended before the day the election is made, in accordance with the following formula: A + B − C where A is the income of the applicant, or the applicant and his or her spouse, from the beginning of the taxation year until the day the election is made, B is the estimate of income of the applicant, or the applicant and his or her spouse, as determined by the minister, from the day the election is made until the end of the taxation year, C is any deductions approved by the minister. 7(3) A determination of annual income under this section is effective from the first day of the benefit year in which it is made. 7(4) [Repealed] M.R. 66/2006 7(5) An election under subsection (1) must be made during the benefit year to which it pertains. M.R. 141/2000 ; 66/2006 PART 3 DRUGS PROVIDED AT NO COST ELIGIBLE PERSONS Persons eligible for benefits 7.1 Persons who are residents as defined in The Health Services Insurance Act and are registered and eligible for benefits under that Act are designated as an eligible class of persons entitled to receive benefits under this Part. M.R. 35/2024 BENEFITS Benefits for drugs for specified purposes 7.2 Benefits are payable to an eligible person under this Part in respect of a specified drug that is (a) specified by the minister under subsection 8.2(2) of the Act as a drug prescribed for the purpose of HIV prevention or treatment; (b) prescribed for the purpose of HIV prevention or treatment for which the minister has specified under subsection 8.2(3) of the Act (specifying drug or item in exceptional circumstances) that a benefit is payable to the eligible person; (c) specified by the minister under subsection 8.2(2) of the Act as a drug prescribed for the purpose of contraception; (d) prescribed for the purpose of contraception for which the minister has specified under subsection 8.2(3) of the Act (specifying drug or item in exceptional circumstances) that a benefit is payable to the eligible person; (e) an oral antiviral drug specified by the minister under subsection 8.2(2) of the Act as a drug prescribed for the purpose of COVID-19 treatment; (f) specified by the minister under subsection 8.2(2) of the Act as a drug prescribed for the purpose of diabetes treatment or control; (g) prescribed for the purpose of diabetes treatment or control for which the minister has specified under subsection 8.2(3) of the Act (specifying drug or item in exceptional circumstances) that a benefit is payable to the eligible person; (h) specified by the minister under subsection 8.2(2) of the Act as a drug prescribed for the purpose of hormone replacement therapy; or (i) prescribed for the purpose of hormone replacement therapy for which the minister has specified under subsection 8.2(3) of the Act (specifying drug or item in exceptional circumstances) that a benefit is payable to the eligible person. M.R. 35/2024 ; 84/2024 ; 106/2024 ; 32/2025 Benefits are cost of specified drugs 7.3(1) The amount of the benefits payable to an eligible person under this Part is the cost of the specified drug incurred by the eligible person. 7.3(2) The person is not entitled to receive a benefit under subsection (1) if the person (a) is entitled to have the cost of the specified drug paid by (i) the government, if the payment is not made under the authority of the Act, (ii) the Government of Canada, (iii) the government of another jurisdiction in Canada or elsewhere, including, without limitation, a municipal government in Manitoba, or (iv) an agent or agency of a government described in any of subclauses (i) to (iii); or (b) has at any time purchased or used the specified drug in breach of the Food and Drugs Act (Canada), the Controlled Drugs and Substances Act (Canada) or The Pharmaceutical Act . M.R. 35/2024 PART 4 GENERAL PROVISIONS BENEFITS SUBJECT TO CONDITIONS Benefits subject to conditions 8(1) Payment of the amount of a benefit for a specified drug is subject to any condition that is specified by the minister in respect of that drug. 8(2) Notwithstanding any other provision of this regulation, in any 90-day period, no benefit is payable for more than the following number of days' supply of a specified drug: (a) 100; and (b) up to an additional 100, if (i) the prior approval of the minister has been obtained, and (ii) the person will be outside of Canada for more than 90 consecutive days. 8(3) For the purpose of subsection (2), the number of days' supply of a specified drug is equal to the quantity of the specified drug dispensed divided by the person's daily dosage requirements for that drug. M.R. 202/96; 141/2000 ; 53/2012 ; 96/2021 DETERMINATION OF ELIGIBILITY BY PHARMACIST Use of electronic data storage system in determining Part 2 benefits 9(1) This section applies to the sale of a specified drug for which a person claims benefits under Part 2 where (a) the pharmacist has access to the electronic data storage system; and (b) the information necessary to determine the person's eligibility for a benefit for the specified drug is available from that system. 9(2) The pharmacist shall ascertain from information in the electronic data storage system whether the person named in the prescription is eligible to receive benefits under this regulation, in which case the purchaser of the specified drug is entitled to receive it without payment to the pharmacist of any amount that is a benefit under this regulation. 9(3) and (4) [Repealed] M.R. 35/2024 M.R. 77/2017 ; 35/2024 Determining Part 3 benefits 9.1(1) This section applies to the sale of a specified drug by a pharmacist for which a person claims benefits under Part 3. 9.1(2) The pharmacist must make reasonable efforts to determine whether the person is eligible to receive the benefits. If the pharmacist determines that the person is eligible, the purchaser of the specified drug is entitled to receive it without payment to the pharmacist of any amount that is a benefit under this regulation. M.R. 35/2024 Minister to pay pharmacist 9.2(1) If a pharmacist has provided a specified drug to an eligible person under section 9 or 9.1, the minister must, as soon as practicable after the drug is provided, pay the pharmacist an amount equal to the benefit to which the eligible person is entitled under this regulation, in which case the payment is deemed to be full payment of the benefit to the eligible person. 9.2(2) On the sale of a specified drug under section 9 or 9.1, or as soon as practicable after the sale, the pharmacist must enter all details of the sale into the electronic data storage system. M.R. 35/2024 TRANSITIONAL, REPEAL AND COMING INTO FORCE Transitional 10 For the benefit year beginning on April 1, 1996 only, the deductible amount determined under subsection 6(1) is to be reduced by the cost of specified drugs incurred collectively by the family unit in the period beginning on January 1, 1996 and ending on March 31, 1996, to a maximum of (a) $134.40, if one or more members of the family unit is 65 years of age or over; and (b) $237.10, in any other case. Transitional: portion of 2003 benefit year 10.1 For the purpose of determining the deductible amount for the benefit year in relation to the cost of specified drugs incurred after March 31, 2003 and before July 1, 2003, in the description of A in the formula in clause 6(1)⁠(b), (a) ".0331" shall be read as ".0315"; and (b) ".0221" shall be read as ".021". M.R. 98/2002 ; 107/2003 Repeal 11 The Prescription Drugs Payment of Benefits Regulation , Manitoba Regulation 102/89, is repealed. Coming into force 12 This regulation comes into force on April 1, 1996. SCHEDULE (Subsection 6(1)) A (Adjusted Family Income) B (Deductible Rate) $0 – $1,000 3.45% $1,001 – $2,000 3.45% $2,001 – $3,000 3.45% $3,001 – $4,000 3.45% $4,001 – $5,000 3.45% $5,001 – $6,000 3.45% $6,001 – $7,000 3.45% $7,001 – $8,000 3.45% $8,001 – $9,000 3.45% $9,001 – $10,000 3.45% $10,001 – $11,000 3.45% $11,001 – $12,000 3.45% $12,001 – $13,000 3.45% $13,001 – $14,000 3.45% $14,001 – $15,000 3.45% $15,001 – $16,000 4.87% $16,001 – $17,000 4.87% $17,001 – $18,000 4.87% $18,001 – $19,000 4.87% $19,001 – $20,000 4.87% $20,001 – $21,000 4.87% $21,001 – $22,000 4.92% $22,001 – $23,000 5.01% $23,001 – $24,000 5.08% $24,001 – $25,000 5.13% $25,001 – $26,000 5.21% $26,001 – $27,000 5.26% $27,001 – $28,000 5.32% $28,001 – $29,000 5.38% $29,001 – $30,000 5.41% $30,001 – $31,000 5.41% $31,001 – $32,000 5.41% $32,001 – $33,000 5.41% $33,001 – $34,000 5.41% $34,001 – $35,000 5.41% $35,001 – $36,000 5.41% $36,001 – $37,000 5.41% $37,001 – $38,000 5.41% $38,001 – $39,000 5.41% $39,001 – $40,000 5.41% $40,001 – $42,500 5.87% $42,501 – $45,000 6.00% $45,001 – $47,500 6.12% $47,501 – $50,000 6.20% $50,001 – $52,500 6.20% $52,501 – $55,000 6.20% $55,001 – $57,500 6.20% $57,501 – $60,000 6.20% $60,001 – $62,500 6.20% $62,501 – $65,000 6.20% $65,001 – $67,500 6.20% $67,501 – $70,000 6.20% $70,001 – $72,500 6.20% $72,501 – $75,000 6.20% $75,001 – $77,500 7.77% $77,501 – $80,000 7.77% $80,001 – $82,500 7.77% $82,501 – $85,000 7.77% $85,001 – $87,500 7.77% $87,501 – $90,000 7.77% $90,001 – $92,500 7.77% $92,501 – $95,000 7.77% $95,001 – $97,500 7.77% $97,501 – $100,000 7.77%  $100,001 and greater 7.77%