Maximum Allowable Cost pricing
On October 1, 2016, Alberta government-sponsored drug programs introduced Maximum Allowable Cost (MAC) pricing for eligible acid reflux medications (known as proton pump inhibitors or PPIs). These medications are used to treat gastroesophageal reflux disease and other acid-related disorders.
Under MAC pricing, only the lowest-cost, generic versions of Pariet (raberprazole) and Tecta (pantoprazole magnesium) will be covered by Alberta government-sponsored drug programs. While there are a variety of PPIs available, clinical evidence shows that all of them are therapeutically similar and equally effective.
Effective February 1, 2017, Alberta government-sponsored drug programs will only pay up to the MAC price and the plan member will be responsible for paying the difference. Physicians may continue to prescribe and plan members may choose any brand name or generic PPI if they wish to stay on their current medication.
If plan members are currently taking a medication that costs more than the MAC price, they can ask their pharmacist to adapt their prescription for the MAC-priced PPI. Special authorization can be considered in those instances when plan members experience a significant allergic reaction or suffer a documented, untoward therapeutic effect with a MAC drug.
Frequently asked questions
What is MAC pricing?
MAC pricing is an approach that defines the maximum amount a plan will pay for the cost of a drug product within a specific grouping of drugs used to treat a common condition. For drugs that have a cost at or below the maximum, there will be no effect on how they are covered by a plan. For drugs that have a cost above the maximum, the plan will only pay up to the maximum amount and the plan member will be responsible for the difference in cost.
Does MAC pricing apply to all Alberta government-sponsored plans or just Group 1 (Non-Group Coverage) and Group 66 (Coverage for Seniors)?
This program applies to all Alberta government-sponsored plans including Group 1, Group 66, Palliative Care and Alberta Human Services.
What drugs are affected by MAC pricing?
MAC pricing will apply to the PPI class. This class of medications is used to treat conditions related to high levels of acid in the stomach, such as heartburn, acid reflux and ulcers. Research shows that medications in this class are similar to each other in both safety and effectiveness.
How do I find out if the PPI that I currently use or will need is subject to MAC pricing?
Plan members will need to obtain the drug identification number (DIN) for the PPI they are inquiring about; then, they can sign in to the Alberta Blue Cross member web site and look up the drug in question. If MAC pricing applies to their drug, information will be available on the site. They can also call Alberta Blue Cross Customer Services or speak to their pharmacist for more information.
What are plan members’ options if their medications are affected by MAC pricing?
If plan members are prescribed a PPI that is at or below the MAC price, they do not need to pay additional costs. If they are prescribed a PPI that is above the MAC price, they have two options:
- Talk to their physician or pharmacist about changing their prescription to a drug that is at or below the MAC price.
- Pay the difference out-of-pocket if they choose to continue on their current medication.
Can a pharmacist change between products in a MAC grouping without approval from a prescriber?
Yes; a pharmacist can adapt the prescription to another product within the MAC grouping when appropriate.
What if a plan member cannot take the lowest-cost PPI?
They will need to speak with their physician or pharmacist for more information. If a plan member experiences a severe allergic reaction to rabeprazole or pantoprazole magnesium, their prescriber can request an exception by submitting a special authorization request form to Alberta Blue Cross.
Where can plan members find additional information about MAC pricing for PPIs?
Plan members can contact their physician or pharmacist for more information. Information about this topic is available on the Alberta Health web site.