Prescription Drug Coverage

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 maximums, and reasonable and customary limits.

The out-of-pocket cap for 2024 is $143 single/$288 family coverage. This represents 20% of a total of $715 in expenses for single or $1,440 in expenses for family.

Predetermination of Coverage

In the event that you expect any significant extended health or dental expenses, it is advisable to submit a cost estimate/predetermination to GSC to confirm how much you can expect to be reimbursed.

To determine if a specific medication/treatment will be covered by our plan we advise you to contact GSCdirectly at 1-888-711-1119 or you can submit a request online to check your coverage.

How to check if you are eligible for an item/service can be found below.

You can first watch the GSC YouTube video

Once you registered and logged into your GSC Everywhere member site, select the button “check your coverage” (bottom left screen).

Predetermination website example

Once selected, you’ll be brought to the following window and all you need to do is now provide information that is required to see if you are eligible for a service.

Please note that you have the opportunity at this point to watch a video on how to submit a claim.

predetermination website example

If you require any assistance during this process, please reach out to GSC directly at 1-888-711-1119.

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 

Drug Compound Eligibility

For a compound to be eligible with Green Shield Canada, it needs to have the following characteristics:

  • Contains an active ingredient in a therapeutic concentration that is considered an eligible benefit
  • Is not a duplication of a formulation of a manufactured pharmaceutical product
  • Not experimental or cosmetic

GSC would be happy to walk you through the eligibility of Compound Drugs. You can contact the GSC Customer Contact Centre at 1-888-711-1119.

For more information, please review GSC's plan member compound policy (PDF).

Prior Authorization

Prior authorization is a program where certain drugs require pre-approval before payment for the claim is made.

Prior authorization drugs tend to be expensive and/or have the potential to be used inappropriately, either through excessive use or for unapproved medical conditions. For each prior authorization drug, GSC establishes medical criteria that you must meet before approval of coverage is granted.

The prior authorization program works for you by ensuring that drugs are taken for the approved medical conditions, treatment follows established guidelines, and that standard first-course drug therapies are tried before second-course treatments are approved. The prior authorization program ensures you receive the best drug options possible.

How to apply for prior authorization

  1. Get a Prescription Drug Special Authorization Form and/or the GSC Eligible Criteria Sheet for the prescribed drug. There are three ways to do this:
    1. Download the forms from the Drug Coverage Search results on GSC everywhere; or
    2. Contact GSC to request the Prescription Drug Special Authorization Request Form and/or the Eligible Criteria Sheet.
      1. By email:
      2. By phone: 1.888.711.1119 or
      3. Ask your pharmacist to print the Prescription Drug Special Authorization Request Form and/or the Eligible Criteria Sheet from the providerConnect® website. Your pharmacist can either give you the forms or fax them directly to your physician (if your physician accepts pharmacy faxes).
  2. Ask your physician to assess your eligibility by reviewing the Eligible Criteria Sheet
    • If you are eligible, complete the Prescription Drug Special Authorization Request Form with your physician.
    • If you are ineligible, ask your physician about alternative drugs or fill the prescription at your own expense.
  3. Submit the Prescription Drug Special Authorization Form to GSC:
    • By email: Scan the document and email to
    • By mail: Green Shield Canada, Attn: Drug Special Authorization, P.O. Box 1606, Windsor, ON N9A 6W1
    • By fax: 1.866.797.6483

The University of Waterloo’s Preferred Provider Network of Pharmacies

For a number of years, a Preferred Provider Network for Pharmacies has been established with local pharmacies. While the use of this program’s 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 this program have agreed to provide guaranteed levels of service, competitive (if not reduced) dispensing fees and competitive drug prices. Some of these pharmacies have also agreed to provide discounts on other non-prescription drug items.

Your Green Shield Canada benefits ID card is required to ensure you receive the program’s prices and discounts where available.

Several local pharmacies have agreed to participate in our Preferred Provider Network for Pharmacies effective January 1, 2023. Refer to The University of Waterloo’s Preferred Provider Network of Pharmacies for further details. Please call pharmacies directly for home delivery information.

Digital Pharmacy (Health Depot)

GSC and The Health Depot have teamed up to bring you convenient and affordable access to the medications and pharmacy services you need –€“ from the comfort of your home.

With The Health Depot, there’s no more waiting in line to drop off your prescriptions or pick them up – your medications will come to you instead. Plus, you get lower prescription costs and free delivery!

Have a question about your medication? No problem. You can call, send an email, or book a virtual appointment –€“ a team of licensed pharmacists is available to answer your questions and provide clinical expertise.

Even better, it’s available to all GSC plan members at no additional cost.

For more information, please visit GSC’s Pharmacy Services link.

Brand Name Drug Approval

If you must take the Brand Name version of a drug due to an adverse reaction to the Generic, your pharmacist or physician will complete a Health Canada adverse drug reaction exception form to be submitted to both GSC and Health Canada. Call GSC if you have questions regarding this process, at 1-888-711-1119.

The brand name drug approval form can be found on the Health Canada website or your doctor’s office, or your pharmacy may be able to provide it for you. Once completed by the medical doctor, the original form is sent to Health Canada Vigilance and the manufacturer, and a copy must be sent to GSC for assessment.

Specialty Care Program

GSC along with NKS Assist, have developed a Specialty Care Program, a preferred pharmacy network to help limit the high cost of specialty drugs for you and your benefits plan and ensure that you get the treatment support you need.

The Specialty Care Program offers you…

  • Potential savings on any out-of-pocket expenses you may be paying for your medication
  • Coordinating any applicable patient assistance programs with your GSC plan
  • Free delivery of your medication, if applicable, directly to your treatment location or any other address of your choice
  • Dispensing of the medication to coordinate with your treatment appointments and communicating with your prescribers if needed

  • Adherence support services to help ensure you take your medication as prescribed

Certain drugs require prior authorization from GSC before your drug claim can be reimbursed. Further, certain drugs defined by GSC as specialty drugs may be required to be purchased from an approved pharmacy that is a member of GSC’s Specialty Care Program before your claim can be reimbursed. You can find out if your drug requires prior authorization or is included in GSC’s Specialty Care Program, either by checking your coverage under “Your Health Benefits” on GSC everywhere or by contacting GSC’s Customer Service Centre.