Presentation (CTI)

OBJECTIVES: To evaluate the average and range of per-member-per-month (PMPM) expenditures reported in budget impact analyses (BIAs) for non-oncology drugs in Canada and to assess variation across disease areas to inform public drug plan decision-making
METHODS: A targeted search of the Canadian Drug Agency (CDA) database identified non-oncology submissions with positive reimbursement decisions and reported BIAs from 2015 to December 2025. When PMPM values were not reported, they were estimated by dividing total monthly budget impact by the number of eligible publicly covered members in Canada (excluding Quebec), per CDA guidance. Mean and range of PMPM costs were estimated across disease categories over a three-year horizon. Costs were inflation-adjusted to 2025 Canadian dollars. Future analyses will include negative reimbursement decisions and published literature.
RESULTS: Of 322 submissions identified, 139 reported BIA results and were included. Most submissions were from recent years following mandatory BIA reporting, which may bias estimates. Rare diseases accounted for 30% of submissions, followed by autoimmune (10%) and respiratory (10%) conditions. Incremental PMPM costs ranged from -$0.32 to $4.62. Cardiometabolic therapies had the highest mean PMPM costs, while ocular therapies were generally cost saving (mean -$0.07). Rare disease PMPM costs ranged from -$0.14 to $1.40. Overall, the mean incremental PMPM cost was $0.24.
CONCLUSIONS: PMPM estimates offer a standardized and policy-relevant metric for comparing budget impact across therapeutic areas and supporting sustainable public drug plan funding decisions. However, substantial variability in PMPM costs underscores the importance of considering disease context, drug acquisition costs, and market uptake assumptions when interpreting BIAs. These findings provide empirical benchmarks that may inform reimbursement deliberations, horizon scanning, and budget planning for Canadian public payers.