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Coverage Categories at Public Drugs Plans in Canada

December 2020

Abbreviations

Abbreviations Full Name
AB Alberta
BC British Columbia
CAF Canadian Armed Forces
CSC Correctional Services Canada
ES Environmental Scan
MB Manitoba
NIHB Non-Insured Health Benefits
NL Newfoundland and Labrador
NS Nova Scotia
ON Ontario
PE Prince Edward Island
QC Quebec
RAMQ Régie de l'assurance maladie du Québec
SK Saskatchewan
VAC Veterans Affairs Canada
YT Yukon

Summary

  • Drugs that are listed in the public drug plan formularies are assigned various coverage categories taking into consideration the limitations and restrictions (if applicable) for the reimbursement of the drugs. This Environmental Scan (ES) provides information on the various coverage categories under which drugs are listed at the 15 Canadian federal, provincial, and territorial drug plans’ formularies.
  • All of the 15 public drug plans have one or more form of restricted coverage category, which can be divided into three groups. Five public drug plans formularies list drugs that are reimbursed when prescribed/dispensed as per the limits and restrictions or terms and conditions stated in the formulary. Four drug plans formularies list drugs that are reimbursed when prescribed/dispensed as per the limits and restrictions stated in the formulary; and require the prescriber to write a pre-specified code for the drug in the prescription. There are 14 drug plans formularies that list drugs that are reimbursed when prescribed/dispensed as per the limits and restrictions stated in the formulary; and require prior approval / special authorization through an established application processes. A variety of terminologies are used to refer to the three types of restricted coverage category, with little consistency across drug plans.
  • Nine drug plans have provision for a case-by-case review process for non-formulary drugs, that is, drugs that do not fall under unrestricted or restricted benefit; thereby requiring an individualized medical review.

Background

Publicly funded federal, provincial, and territorial drug plans provide coverage for eligible drugs to eligible populations within their jurisdictions. These eligible drugs, listed in the public drug plans’ formularies, are assigned various coverage categories; that is, the formulary benefit status terminology used by jurisdictions that can be broadly classified as unrestricted or restricted benefits.1,2

Unrestricted benefit refers to drugs that are covered by a drug plan without any limits or restriction for reimbursement. Depending on the drug plan, this type of formulary benefit status is referred to as benefit, open benefit, full benefit, general benefit, standard benefit, or regular benefit.1,2

Restricted benefit refers to drugs that are covered with certain limits or restrictions for reimbursement, such as quantity or frequency limits, specific clinical criteria limits, or defined patient subgroup or prescriber/specialist limits. Restricted benefit can be divided into three groups:1,3-27

  • Drugs that are reimbursed when prescribed/dispensed as per the limits and restrictions stated in the formulary.
  • Drugs that are reimbursed when prescribed/dispensed as per the limits and restrictions stated in the formulary and require the prescriber to write a pre-specified code for the drug in the prescription.
  • Drugs that are reimbursed when prescribed/dispensed as per the limits and restrictions stated in the formulary; and require prior approval /special authorization. There is a requirement to apply for reimbursement, with the required clinical details by the authorized prescriber using established application processes (e.g., use of specific authorization forms). Each request is subject to a medication review by staff responsible for claims adjudication at the public drug plan before approval for coverage is granted.

Depending on the level of limit or restriction and requirement for prior approval, drug plans refer to the restricted benefit status as special authorization, exceptional access program, exceptional drug status, limited use, limited coverage drug, or prior authorization.

Under certain circumstances, some drug plans may also consider covering certain drugs that are not routinely covered (through restricted or unrestricted benefit) on a case-by-case basis; that is, it requires an individualized medical review.3-5,7-9,12-14,20,21,24,25

Objectives

This ES provides information on the various coverage categories under which drugs are listed in the Canadian federal, provincial, and territorial drug plans’ formularies for reimbursement.

Methods

The findings of this ES are based on information obtained from the Canadian public drug plan formulary websites. No bibliographic literature searches were performed. Official websites of the Canadian public drug plans were searched between October 10, 2020 and October 30, 2020. Information was gathered from the following 15 publicly funded drug plans (10 provincial, one territorial, and four federal drug plans) listed below:

Provincial/territorial plans

  • Alberta (AB) Drug Benefit List
  • British Columbia (BC) Pharmacare Formulary
  • Manitoba (MB) Pharmacare Drug Formulary
  • New Brunswick (NB) Drug Plan Formulary
  • Newfoundland and Labrador (NL) Prescription Drug Program Formulary
  • Nova Scotia (NS) Pharmacare Formulary
  • Ontario (ON) Drug Benefit Formulary
  • Régie de l'assurance maladie du Québec (RAMQ in QC)
  • Prince Edward Island (PE) Pharmacare Formulary
  • Saskatchewan (SK) Formulary
  • Yukon (YT) Drug Formulary

Federal plans

  • Canadian Armed Forces (CAF) Drug Benefit List
  • Correctional Services Canada (CSC) National Formulary
  • Non-Insured Health Benefits (NIHB) Drug Benefit List
  • Veterans Affairs Canada (VAC) Drug Formulary

It should be noted that publicly reimbursed medications for residents of Nunavut and the Northwest Territories follow the coverage category and reimbursement criteria of the NIHB program.28,29

Research Questions

The following research question was addressed:

  • What are the various coverage categories and the respective terminologies, under which reimbursed drugs are categorized by the Canadian federal, provincial, and territorial drug plans

Consultations

  • Representatives from the federal, provincial, and territorial health ministries were consulted to validate the information gathered from the public drug plans’ websites.30 The consultation period ended on November 17, 2020; therefore, the information summarized in this report is up-to-date as of November 17, 2020. The information regarding coverage categories was validated by representatives from 10 provincial and territorial drug plans (AB, BC, MB, NB, NL, NS, ON, QC, PE, and SK); and from the four federal drug plans (CAF, CSC, NIHB, and VAC).
  • Some information presented in this report was not available in the public domain and was obtained through personal communication with representatives from the federal, provincial, and territorial health ministries. When this occurred, permission was obtained to publish this information in this report and all details obtained through personal communication were referenced accordingly.

Findings

The following section presents a summary of the findings relating to coverage categories for eligible drugs at the 15 public drug plans. Public drug plans provide coverage for drugs under various programs, which are based on age (e.g., seniors), income (pre-specified income threshold), or a medical condition (e.g., cystic fibrosis, cancer) among others. The formularies listed below may be applicable to more than one drug program for a given drug plan. Of note, Canadian provincial and territorial abbreviations are used to refer to the respective jurisdictional drug plan formularies. It should be noted that publicly reimbursed medications for residents of Nunavut and the Northwest Territories follow the coverage category and reimbursement criteria of the NIHB program.28,29

Table 1 provides an overview of the coverage categories at the 15 public drug plan formularies, and the respective terminologies used by the drug plans to refer to these categories.

  1. Unrestricted Benefit

Unrestricted benefit, which is one of the benefit status categories, is defined as the following across the 15 public drug plans:

  • benefit (QC, NS, PE, YT)
  • regular benefit (BC, AB, SK, NB, CAF)
  • open benefit (NL, NIHB, CSC)
  • general benefit (ON)
  • standard benefit (VAC)
  • part 1 benefit (MB).

There are no limits or restriction for reimbursement for drugs that are assigned this status. Overall, the majority of the drugs within each drug plan fall under the unrestricted benefit coverage category.3-27

  1. Restricted Benefit

There is one or more forms of restricted benefit category at all of the 15 public drug plans. Details on the restricted coverage categories at each drug plan is provided in Appendix 1.

  1. AB, MB, QC, NL, and NIHB formularies list drugs that are reimbursed when prescribed/dispensed as per the limits and restrictions or terms and conditions stated in the formulary. These limits and restrictions could be in terms of quantity limits, frequency limits, limited to certain patient subgroups (e.g., specific age group), or prescribed by a certain specialist. When prescribed within the limits and restrictions or terms and conditions — as specified in the formularies — further approval is not required.4,9,15,21,27 This benefit status is referred as the following:
    • restricted benefit (AB, QC)
    • limited restricted benefit (AB)
    • part 2 benefit (MB)
    • open benefit with limitations (NL)
    • limited Use – no prior authorization required (NIHB).

      AB also has a process for step therapy, whereby if a patient has made a claim for the first-line drug product(s) within the preceding 12 months, the claim for the step therapy drug product will be approved. A first-line drug product includes any drug(s) or drug product(s) that, under the Drug Products Special Authorization criteria, are required to be utilized before reimbursement for the step therapy drug product is permitted.26

      AB may allow optional special authorization for some drugs (within the prior approval/special authorization category as noted later in this document), where prior approval is not needed if certain clinical and/or prescriber criteria are met.26

Some drugs are covered only under special medical circumstances to ensure its appropriate use, and access to these drugs are limited through the following two mechanisms.

  1. ON, QC, NS, and CSC formularies list drugs that are reimbursed when prescribed/dispensed as per the limits and restrictions stated in the formulary; and require the prescriber to write a pre-specified code for the drug in the prescription.6,9,13,24 In ON and CSC, the pre-specified code that is written on the prescription is known as RFU code.13,24 A specific terminology used to refer to the pre-specified code written on the prescription was not identified for QC, and it was referred to as code. In NS, the pre-specified code that is written on the prescription is known as criteria code. In NS, some exception status drugs are assigned such criteria code to allow the drugs to be prescribed /dispensed without SA, as long as the criteria code is stated in the prescription.6

    This benefit status is referred to as the following:
    • limited use (ON), — RFU code required
    • exceptional medication — coded (QC) — code required
    • exception status drug with criteria code (NS) — criteria code required
    • benefit with criteria (CSC) RFU code required.
  1. Except for CSC, all other 14 drug plans (AB, BC, SK, MB, ON, QC, NB, NS, NL, PE, YT, NIHB, VAC, and CAF) formularies list drugs that are reimbursed when prescribed/dispensed as per the limits and restrictions stated in the formulary; and require prior approval/SA. There is a requirement to apply for reimbursement, with the required clinical details by the authorized prescriber using established application processes (e.g., use of specific authorization forms). Each request is subject to a medication review by staff responsible for claims adjudication at the public drug plan before approval for coverage.5-12,16,18,19,21-23,25,26 This benefit status is referred to as the following:
    • special authorization (AB, NB, NL, PE, VAC, CAF)
    • exception drug status (SK, YT)
    • exception status drugs (NS)
    • part 3 exception drug status (MB)
    • exceptional access program (ON)
    • exceptional medication — uncoded (QC)
    • limited use — prior authorization required (NIHB)
    • special authority/limited coverage drug (BC).

      Depending on the drug plan, the medication and the condition being treated, the duration of approval may range from a one time only fill to coverage with no end date. Some drug plans may provide retroactive coverage, that is coverage may be provided for a specified period of time after the application is received (but under review, that is, before a decision has been made) to ensure immediate access to the drugs. For example, in YT, the Formulary Working Group reviews applications noted as Exception Drug coverage on a monthly basis; hence, to provide coverage until the application is reviewed, a 30-day approval for the patient may be requested. If a 30-day approval was granted and the exception application was approved, the client will continue to be covered. If declined, the program will discontinue payment after 30 days.
  1. Non-Formulary Review Process

Under certain circumstances, some drug plans may also consider coverage for certain drugs that is not routinely provided through restricted or unrestricted benefit on a case-by-case basis, that is, it requires individualized medical review.3,7-9,12-14,21,24,25 BC, SK, ON, QC, NB, NS, NL, NIHB, and CSC have provision for non-formulary case-by case review process for drugs that are not currently a benefit with the drug plan. This provision is referred to as the following:

  • exceptional case-by-case review (SK)
  • compassionate review policy (ON)
  • exception patient program (QC)
  • formulary exception review process (NB)
  • exception review process (NL)
  • exception (NIHB)
  • exception benefit (CSC).

NS may also consider coverage for non-benefit drugs in exceptional circumstances with a written request from a prescriber.31 BC does not have an official provision for a case-by case review, but the drug plan does complete case-by-case reviews of drugs that are non-benefit through the general Special Authority mechanism. (Clifford Lo, BC Pharmacare Formulary: personal communication, Nov 2020). NIHB also has an appeals process available in circumstances when coverage for a benefit through the NIHB program is denied.20

Table 1 presents information on the coverage category (grouped as unrestricted benefit, restricted benefit, and provision for case-by-case review of non-formulary drugs) for each public drug plan. Appendix 1 provides a detailed overview of the restricted coverage category, that is the formulary benefit status terminology used by jurisdictions.

Table 1: Coverage Categories at Canadian Public Drug Plan Formularies and Provision for Case-By-Case Review of Non-Formulary Drugs

Public drug plan formulary

Unrestricted benefit

Restricted benefita

Provision for a case-by-case review of non-forumary drugs

Reimbursed when prescribed /dispensed as per the limits and restrictions stated in the formulary

Reimbursed when prescribed /dispensed as per the limits and restrictions stated in the formulary

Reimbursed when prescribed /dispensed as per the limits and restrictions stated in the formulary

British Columbia Pharmacare Formulary

Regular benefit

NA

NA

Special authority/ limited coverage drug

Case-by case review availablec

Alberta Drug Benefit List

Regular benefit

  • Restricted benefit
  • Limited restricted benefit
  • Step therapy
  • Optional special authorization

NA

Special Authorization

NA

Saskatchewan Formulary

Regular benefit

NA

NA

Exception drug status

Exceptional case-by-case review

Manitoba Drug Benefits and Interchangeability Formulary

Part 1 benefit

Part 2 Benefit

NA

Part 3 (exception drug status)

NA

Ontario Drug Benefit Formulary

General benefit

NA

Limited Use -RFU code required

Exceptional Access Program

Compassionate Review Policy

RAMQ List of Medication

Benefit

Restricted Benefit

Exceptional Medication —Codedcode required

Exceptional Medication —uncoded

Exception Patient Program

New Brunswick Drug Plans Formulary

Regular benefit

NA

NA

Special Authorization

Formulary Exception Review Process

Nova Scotia Pharmacare Formulary

Benefit

NA

 Exception Status Drug with criteria code – criteria code required

Exception status drug

Case-by case review available

The Newfoundland and Labrador Prescription Drug 
Program Formulary

Open benefit

Open Benefit with limitations

NA

Special authorization

Exception review process

Prince Edward Island Pharmacare Formulary

Benefit

NA

NA

Special authorization

NA

Yukon Pharmacare Formulary

Benefit

NA

NA

Exception drug status

NA

Non-Insured Health Benefits Formularyb

Open benefit

  • Limited use (no PA required)
  • Limited use (no PA required; quantity/ frequency limits)

NA

Limited use (PA required)

  • Exception
  • Appeals

Correctional Services Canada Formulary

Open benefit

NA

Benefit with criteria – RFU code required

NA

Exception benefit

Veterans Affairs Canada Formulary

Standard benefit

NA

NA

Special authorization

NA

Canadian Armed Forces Formulary

Regular benefit

NA

NA

Special authorization

NA

NA = not applicable; PA = prior authorization; RAMQ = Régie de l’assurance maladie du Québec; RFU = reason for use.

a See Appendix 1 for details on various categories of restricted benefits at each drug plan.

b Also applicable to Nunavut and the Northwest Territories.

c Clifford Lo, BC Pharmacare Formulary: personal communication, Nov 2020.

Source: Canadian public drug plan formularies.3-29,31

Conclusions

Publicly funded federal, provincial, and territorial drug plans provide coverage for eligible drugs to eligible populations within their jurisdictions. However, some drugs have restricted access, primarily to ensure their appropriate use. As such, drug plans assign drugs listed in their formularies various benefit statuses taking into consideration the limitations and restrictions (if applicable) for the reimbursement of the drugs. This ES provides information on the various coverage categories under which drugs are listed at the 15 Canadian federal, provincial, and territorial drug plans’ formularies for reimbursement. The information in this report was collected from the public domain — namely, the public drug plan websites — and subsequently validated by 14 drug plans.

The coverage categories can be broadly classified as unrestricted and restricted benefit. Overall, the majority of the drugs within each drug plan fall under the unrestricted benefit category, where there are no limits or restrictions for reimbursement for drugs that are assigned this status.

All of the 15 public drug plans have one or more types of restricted benefit category, whereby drugs are covered with certain limits or restrictions for reimbursement, such as quantity or frequency limits, limited by specific clinical criteria, or limited to a defined patient subgroup or prescriber/specialist. Five drug plans (AB, MB, QC, NL, and NIHB) formularies list drugs that are reimbursed when prescribed and dispensed as per the limits and restrictions or terms and conditions stated in the formulary. Four drug plans’ (ON, QC, NS, and CSC) formularies list drugs that are reimbursed when prescribed/dispensed as per the limits and restrictions stated in the formulary; and require the prescriber to write a pre-specified code for the drug in the prescription. There are 14 drug plans’ (AB, BC, SK, MB, ON, QC, NB, NS, NL, PE, YT, NIHB, VAC, and CAF) formularies that list drugs that are reimbursed when prescribed/dispensed as per the limits and restrictions stated in the formulary; and require prior approval/special authorization. For this benefit status, there is a requirement to apply for reimbursement, with the required clinical details by the authorized prescriber using established application processes (e.g., use of specific authorization forms).

Nine drug plans (BC, SK, ON, QC, NB, NS, NL, NIHB, and CSC) have provision for a case-by-case review process for non-formulary drugs, that is, drugs that do not fall under unrestricted or restricted benefit; thereby requiring an individualized medical review.

There are different terminologies used to refer to the unrestricted coverage category; the most common terms used by drug plans are regular benefit, open benefit, or benefit. A variety of terminologies are used to refer to the three types of restricted coverage category, with little consistency between drug plans; except for special authorization or exception drug that are used by 10 drug plans to identify drugs that require prior authorization. Similarly, there is a lack of consistency across the terms used to refer to the case-by-case review process for non-formulary drugs used by drug plans.

References

  1. Canadian Institute for Health Information. National Prescription Drug Utilization Information System. Plan Information Document. 2020: https://secure.cihi.ca/estore/productFamily.htm?pf=PFC4324&lang=en&media=0. Accessed 2020 November 01.
  2. Patented Medicine Prices Review Board. Alignment among public formularies in Canada part 1: general overview. 2019: http://www.pmprb-cepmb.gc.ca/view.asp?ccid=1327. Accessed 2020 October 20.
  3. Government of Newfoundland and Labrador Health and Community Services. Exceptional Review Process. 2020. https://www.gov.nl.ca/hcs/prescription/erp/. Accessed 2020 October 20.
  4. Government of Newfoundland and Labrador Health and Community Services. Open Benefit Drug Products. 2020. https://www.gov.nl.ca/hcs/prescription/covered-openbenefitdrugs/. Accessed 2020 October 20.
  5. Government of Newfoundland and Labrador Health and Community Services. Special authorization drug products. 2019. https://www.gov.nl.ca/hcs/prescription/covered-specialauthdrugs/. Accessed 2020 October 20.
  6. Government of Nova Scotia. Formulary. 2020. https://novascotia.ca/dhw/pharmacare/documents/formulary.pdf. Accessed 2020 October 22.
  7. Government of Saskatchewan. APPENDIX A: EXCEPTION DRUG STATUS PROGRAM. 2020. http://formulary.drugplan.health.gov.sk.ca/PDFs/APPENDIXA.pdf. Accessed 2020 October 30.
  8. Government of Saskatchewan. About the Saskatchewan Formulary. 2020. http://formulary.drugplan.health.gov.sk.ca/About. Accessed 2020 October 30.
  9. Régie de l'assurance maladie du Québec. Know the conditions for coverage. 2020. https://www.ramq.gouv.qc.ca/en/citizens/prescription-drug-insurance/know.... Accessed 2020 October 23.
  10. Yukon Drug Programs. Yukon drug formulary. 2020. http://apps.gov.yk.ca/drugs/f?p=161:9000:2963908297689238. Accessed 2020 October 23.
  11. Health PEI. PEI pharmacare formulary. 2020. https://www.princeedwardisland.ca/sites/default/files/publications/pei_p.... Accessed 2020 October 22.
  12. Ministry of Health Ontario. Exceptional Access Program. 2020. http://www.health.gov.on.ca/en/pro/programs/drugs/eap_mn.aspx. Accessed 2020 October 25.
  13. Ministry of Health Ontario. Get coverage for prescription drugs- limited use drugs. 2020. https://www.ontario.ca/page/get-coverage-prescription-drugs#section-5. Accessed 2020 October 25.
  14. Ministry of Health Ontario. Applying to the Exceptional Access Program. 2020. https://www.ontario.ca/page/applying-exceptional-access-program. Accessed 2020 October 25.
  15. Manitoba Health. Drug Benefits & Interchangeability Formulary. 2020. https://www.gov.mb.ca/health/mdbif/index.html. Accessed 2020 October 27.
  16. Manitoba Health. Part 3 Exception Drug Status (Eds). 2020. https://www.gov.mb.ca/health/mdbif/docs/edsnotice.pdf. Accessed 2020 October 27.
  17. British Columbia Ministry of Health. 6.1 Benefit Status Types. 2020. https://www2.gov.bc.ca/gov/content/health/practitioner-professional-reso.... Accessed 2020 October 23.
  18. British Columbia Ministry of Health. Special Authority. 2020. https://www2.gov.bc.ca/gov/content/health/practitioner-professional-reso... Accessed 2020 October 24.
  19. Veterans Affairs Canada. What is the VAC drug formulary? 2019. https://www.veterans.gc.ca/eng/financial-support/medical-costs/treatment.... Accessed 2020 October 22.
  20. Indigenous Services Canada. Appealing a decision under the NIHB program. 2020. https://www.sac-isc.gc.ca/eng/1579792696583/1579792732972. Accessed 2020 November 10.
  21. Indigenous Services Canada. Non-insured health benefits: drug benefit list. 2020. https://www.sac-isc.gc.ca/DAM/DAM-ISC-SAC/DAM-HLTH/STAGING/texte-text/ni.... Accessed 2020 October 24.
  22. Government of Canada. CAF Supplemental health care. 2019. https://www.canada.ca/en/department-national-defence/services/benefits-m.... Accessed 2020 October 22.
  23. Government of Canada. Canadian Armed Forces drug benefit list. 2019. http://www.cmp-cpm.forces.gc.ca/hs/en/drug-benefit-list/index.asp. Accessed 2020 October 22.
  24. Correctional Services Canada. CSC National Formulary. 2020 Apr.
  25. Government of New Brunswick. New Brunswick Drug Plans Formulary. 2020. https://www2.gnb.ca/content/gnb/en/departments/health/MedicarePrescripti.... Accessed 2020 October 22.
  26. Government of Alberta. SPECIAL AUTHORIZATION GUIDELINES. 2020: https://www.ab.bluecross.ca/dbl/pdfs/dbl_sec1_sa.pdf Accessed 2020 October 25.
  27. Government of Alberta. Drug Benefit Lists Table of Contents. 2019. https://www.ab.bluecross.ca/dbl/contents.php. Accessed 2020 October 25.
  28. The Government of Nunavut. EHB full coverage plan. 2020. https://www.gov.nu.ca/health/information/ehb-full-coverage-plan. Accessed 2020 October 26.
  29. Government of the Northwest Territories (GNWT). Extended health benefits for specified disease conditions program. 2019: https://www.hss.gov.nt.ca/en/services/supplementary-health-benefits/extended-health-benefits-specified-disease-conditions. Accessed 2020 October 22.
  30. CADTH. Pharmaceutical Advisory Committee Formulary Working Group for Health Technology Assessments. 2020: https://www.cadth.ca/collaboration-and-outreach/advisory-bodies/dpac-fwg-hta. Accessed 2020 October 20.
  31. Government of Nova Scotia. Pharmacy Guide. 2020. https://novascotia.ca/dhw/pharmacare/documents/Pharmacy-Guide.pdf. Accessed 2020 November 10.

About This Document

Author: Sirjana Pant

Cite As: Coverage Categories at Public Drug Plans in Canada. Ottawa: CADTH; 2020 Dec. (CADTH environmental scan).

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  1. Government of Alberta. Drug Benefit Lists Table of Contents. 2019. https://www.ab.bluecross.ca/dbl/contents.php. Accessed 2020 October 25.
  2. The Government of Nunavut. EHB full coverage plan. 2020. https://www.gov.nu.ca/health/information/ehb-full-coverage-plan. Accessed 2020 October 26.
  3. Government of the Northwest Territories (GNWT). Extended health benefits for specified disease conditions program. 2019: https://www.hss.gov.nt.ca/en/services/supplementary-health-benefits/exte.... Accessed 2020 October 22.
  4. CADTH. Pharmaceutical Advisory Committee Formulary Working Group for Health Technology Assessments. 2020: https://www.cadth.ca/collaboration-and-outreach/advisory-bodies/dpac-fwg.... Accessed 2020 October 20.
  5. Government of Nova Scotia. Pharmacy Guide. 2020. https://novascotia.ca/dhw/pharmacare/documents/Pharmacy-Guide.pdf. Accessed 2020 November 10.