FAQ - Prescription drug insurance

The total amount that’s shown on your prescription drug bill is made up of a number of charges. Here are the costs that make up the full price of a prescription drug:

The ‘drug cost’ is normally the same in all pharmacies, but pharmacists’ mark-ups and dispensing fees can vary a great deal. It’s in your best interests to shop around and compare prices at the different pharmacies in your area.

Because of these price differences, we set caps on pharmacy mark-ups and dispensing fees based on the average amounts submitted by all the pharmacists in your province.

It’s important to remember that price isn’t everything; your relationship with your pharmacist is also important. The goal is to strike a good balance between cost and quality service.

When you submit a drug claim, if the amount of the claim is lower than or equal to the cap, you don’t have to pay anything extra for the mark-up or dispensing fee. However, if the amount claimed is higher, you have to pay the difference.

Read the explanation of benefits that we issue for each of your claims. If the terms of your contract require you to pay an additional amount, you’ll see an explanation at the bottom of the page.

You can find your explanation of benefits on the secure site. See a sample explanation of benefits:

Did you know that, on average, generic drugs cost 35% to 70% less than their brand name equivalents? That’s why your insurer has introduced a measure called Generic substitution.

Simply put, generic substitution uses the cost of the equivalent generic drug to calculate your reimbursement. So if you opt for the brand name drug when a generic equivalent is available, you’ll have to cover the difference in price, on top of the amount you’d normally have to pay.

Your plan may have one of two generic substitution options: mandatory or non-mandatory. To find out, consult the Percentage of reimbursement section of the Benefit Schedule at the beginning of your insurance contract.

• If the schedule does include the term “NO SUBSTITUTION”, your plan has non-mandatory generic substitution. If you can’t take the generic version for medical reasons, and your doctor writes “no substitution” on your prescription, it will automatically trigger the exemption and we’ll use the brand name price to calculate your reimbursement, even if there’s a generic drug available.
• If the schedule does not include the term “NO SUBSTITUTION”, your plan has mandatory generic substitution. In this case, if you can’t take the generic version for medical reasons, a “no substitution” order isn’t enough. Your doctor will have to fill out a Request for reimbursement of brand name medications (PDF, 1 MB) Opens in a new window.. form so that we can analyze the request and make a decision.

Critical or rare illnesses often require new drugs that can cost several thousands of dollars a year. Your group insurance plan helps cover all or part of these costs, but certain drugs—mainly very expensive drugs or drugs with a risk of misuse—require prior authorization before you can be reimbursed.

The prior authorization process requires your doctor to fill out a form confirming that a drug was prescribed for its intended use and that it meets our criteria. These criteria are similar to those used by provincial drug insurance plans.

Prior authorization allows you to receive a full or partial reimbursement for drugs that could otherwise cost you thousands of dollars a year. This process also favours the use of less expensive drugs with a proven track record, which helps keep your group insurance premium from going up.

To find out whether your drug needs prior authorization, just ask your doctor. Doctors generally know which medications require prior authorization, and they can suggest alternatives. You can also consult the list of drugs that require prior authorization.

It’s important to note that the list is updated regularly to reflect new drug information and ongoing changes to group insurance plans. This means that we may require prior authorization for a drug you’re already taking if it is added to the list.