Out-of-pocket cap
Eligible paramedical and drug expenses are shared 80% by the plan and 20% out-of-pocket by the employee. Once the employee reaches the out-of-pocket cap, the plan pays 100% of eligible expenses, subject to benefit maxima.
The out-of-pocket cap for 2021 is $130 single/$262 family coverage. This represents 20% of a total of $650 in expenses for single or $1,310 in expenses for family.
Drug coverage
There is a $7 maximum dispensing fee cap for prescription drugs. The employee must pay any amount above this level. The benefit has a maximum allowable dispensing fee for eligible prescription drugs. If the drug fee exceeds the dispensing fee cap, the difference in values is the responsibility of the employee and the fee is not applied to the employees out of pocket amount.
Prescription drug management programs
Trial prescription drug program
The drug benefit includes a voluntary trial prescription drug program for which an employee can choose to limit the initial dispensing of their maintenance medication to seven days. The balance of the prescription can be filled by the employee if the drug is tolerated. The reason for the trial program is to limit waste and costs when a new medication may not be suitable or tolerated by the employee. Dispensing fees above the cap remain the responsibility of the employee. Employees may choose to opt-out of the trial program and fill their full prescription by asking their pharmacist.
Enhanced generic drug substitution
With enhanced generic drug substitution, prescription drugs are automatically substituted for the generic version and coverage to the plan member will be based on the cost of the generic drug. A generic drug is one that shares the same active medicinal ingredient to the brand name version and is available to consumers once a patent has expired. Prior authorization is required for specific non generic drugs. To request specific non-generic drugs, eligible plan members and their physicians can complete a Request for Brand Name Coverage Form .
Canada Life maintains a prior authorization drug list and the corresponding request forms for each specific drug. The drug listing is reviewed on an annual basis to determine whether any drugs should be removed from this process. To obtain a current listing and the corresponding forms, visit: Canada Life’s website.
The Health Case Management (HCM) program
The Health Case Management (HCM) program is designed to assist members who require specialty medications or require complex treatment plans. Plan members who have been prescribed certain specialty drugs will be connected with a health case manager who, along with the physician, will help to monitor a patient’s treatment plan to ensure its effectiveness. If you or one of your dependents apply for prior authorization of certain supplies or services, Canada Life may contact you to participate in the HCM program. Visit www.canadalife.com for more information.
The Sustained, Managed and Reasonable Treatment (SMART) Drug Plan
The Sustained, Managed and Reasonable Treatment (SMART) Drug Plan helps determine if a new drug or new indication for an existing drug is eligible for plan coverage. The SMART plan is designed to target medications that make a significant impact to drug plans, thereby reducing the cost to plan members. Under this program, drugs are added to the plan only if they are cost and clinically effective, generally this occurs when a new drug is approved by Health Canada.
Preferred provider network of pharmacies
For a number of years a Preferred Provider Network (PPN) has been established with local pharmacies. While the use of PPN pharmacies is voluntary, the University is committed to providing its employees with sufficient information to spend health care dollars in the most cost-effective ways.
Pharmacies that participate in the PPN have agreed to provide guaranteed levels of service, competitive (if not reduced) dispensing fees and competitive drug prices. Some of the PPN pharmacies have also agreed to provide discounts on other non-prescription drug items.
Your benefits ID card is required to ensure PPN prices and discounts where available.
Several local pharmacies have agreed to participate in our PPN effective January 1, 2021. Refer to the PPN website for further details. Please call pharmacies directly for home delivery information.
Predetermination of coverage
To determine if a specific medication/treatment will be covered by our plan we advise you to contact Canada Life (formerly Great-West Life) directly at 1-800-957-9777.
In the event that you expect any significant extended health or dental expenses, it is advisable to submit a cost estimate/predetermination to Canada Life (formerly Great-West Life) to confirm how much you can expect to be reimbursed.
