5.23 Pricing Exceptions where Multiple Dosage Forms or Strengths are Available

General Policy Description

To ensure the best value is obtained for expenditures on drugs available in multiple dosage forms and/or strengths, PharmaCare may limit reimbursement of a particular dosage form or strength to the cost of a lower cost dosage form and/or strength.

Policy Details

PharmaCare may limit reimbursement of a particular dosage form or strength to the cost of a lower, or the lowest, priced dosage form and/or strength of a drug.

For example,

• If the price of the capsule, sustained release or enteric-coated tablet is significantly higher than the price of the tablet, prices may be based on that of the tablet.
• If a product strength is priced significantly higher (proportionally) than the price of other strengths, prices may be pro-rated based on that of the lowest cost strength.
• If the price of the suspension is significantly higher than the price of the solution, prices may be based on that of the solution.
• For creams and ointments, if the per-unit price of the tube is significantly higher than the per-unit price of the jar, prices may be based on that of the jar.

To determine the specific pricing exceptions in force under this policy, refer to LCA Pricing Exceptions.