Public Reimbursement Policies for Oncology Medicines in Canada

Key Messages

What Is the Issue?

• Oncology medications can be broadly classified into treatments that are administered in a hospital and treatments that can be taken in the home setting.
• In Canada, public drug plan reimbursement for oncology medication varies between federal, provincial, and territorial (FPT) jurisdictions, and depending on the setting of administration.

What Did We Do?

• We conducted a literature search of key resources, including the websites of health care agencies in Canada and FPT public drug programs as well as a focused internet search. This information was validated and supplemented with details gathered from surveying FPT public drug plans.

What Did We Find?

• Most public drug programs provide coverage for hospital-administered oncology medications listed on their formulary, with no cost to patients.
• Between jurisdictions, there is variability in terms of public reimbursement of take-home oncology medications:
  • Some jurisdictions provide full coverage for take-home oncology medications if the medication is listed on their formulary and the patient meets prespecified clinical criteria, while other jurisdictions limit coverage to patients eligible for a specific drug plan.
  • In some cases, patients may receive varying levels of reimbursement depending on the drug plan they are enrolled in, and some may incur additional out-of-pocket costs.
• Nearly all jurisdictions provide alternative pathways for the reimbursement of oncology medications not listed on their formulary.
• Key differences between jurisdictions include how supportive medications are defined, the availability of programs covering high-cost treatments, and if and how CAR T-cell therapy is reimbursed.

What Does It Mean?

• While most jurisdictions provide access to oncology medications delivered in hospital settings at no cost to patients, coverage for take-home medications is often dependent on specific eligibility criteria, income thresholds, patient age, and the availability of private insurance.
• There may be opportunities for future alignment of oncology medication funding policies across public drug plans in Canada, including alignment of definitions for hospital-administered, take-home, and supportive care