Prescriptions Drugs
The Benefit year is from January 1st to December 31st.
The Plan has a dispensing fee cap of $8 per script up to a combined maximum of $1,000 per year.
The annual combined drug maximum is $10,000 per person per calendar year.
The following drugs and supplies are covered when prescribed by a doctor or dentist and are obtained from a pharmacist:
- All Eligible single-source or multi-sourced brand name drugs and generic drugs, reimbursed at 100% of the lowest generic or biosimilar equivalent cost up to an overall annual maximum of $10,000. Brand name only paid 100% if NO generic is available.
- The plan pays for most drugs that legally require a written prescription and some life-sustaining Over the Counter drugs (OTCs). Examples of these OTC items include insulin, diabetic test strips, disposable insulin needles and syringes, Epi-Pen, and nitroglycerin.
- Professional Fees (Dispensing Fees) are covered to an overall combined maximum of $1,000 per person per calendar year
- All Opiates and Opioids are covered for $600 per person per calendar year
- Immunizations and Vaccines (oral or injected) require a physician’s referral
- Erectile Dysfunction drugs are covered to $500 per person per calendar year
- Freestyle Libre covered only for Insulin-Dependent claimants.
- Prescribed smoking cessation products covered at 2 courses of treatment per person every 3 calendar years to a maximum of $1,000.
The plan covers up to a 34-day supply of acute drugs, and up to a 100- day supply for maintenance drugs.
If you are over 65 live in Ontario and have a valid Ontario Health Card, you qualify for ODB coverage. The ODB program (Ontario Drug Benefit) is the first payer, meaning that any drug costs must go through the ODB first, prior to being submitted to your benefits plan. Once ODB has provided the available coverage, the remainder of the unpaid costs, if any can go through your benefits plan. Some drugs may need to go through the Provincial Exceptional Access Program. Members will be allowed coverage up to 90 days while the application is being processed.
Dispensing Fees
Covered expenses under the drug plan include both the ingredient cost and the dispensing fee. Pharmacies within the same chain can have different dispensing fees. Fees depend on location, with higher fees paid to pharmacies in rural areas. Therefore, it is in your own best interest to shop around for a pharmacy that will accept the $8 dispensing fee cap allowed under this Plan as full payment.
You and your Dependents cannot use the drug card to purchase the following items:
- alcohol swabs
- appliances
- atomizers
- certain equipment
- ostomy supplies
- devices for giving inhaled medications (for example, an aero chamber), blood glucose monitors and prosthetic devices
Exclusions
- alcohol
- cotton
- bandages
- contraceptives, other than birth control pills, maximum $500/year
- cosmetic items
- cotton
- disinfectants
- Over The Counter (OTC) drugs (including a low dosage Aspirin)
- OTC vitamins (including vitamin D3 under 10,000ui) and supplements, even if prescribed by a medical practitioner
- fertility drugs
- hair growth stimulants
- homeopathic medicines
- non-disposable insulin injectors
- OTC medications, vitamins, and supplements, even if prescribed by a medical practitioner
- products that can be bought without a prescription, other than some life-supporting products
- prescription drugs and medications acquired unlawfully for use or prescribed by a non-medical practitioner
- spring loaded devices used to hold lancets
- sunscreens
- spring loaded devices used to hold lancets
- vitamins (except for some injectable items), minerals, dietary supplements, food substitutes, infant food or life-supporting products