Prescription Drug Coverage

If you expect any significant extended health or dental expenses, it is advisable to submit a cost estimate/predetermination to GS 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 GS directly at 1-888-711-1119 or, you can submit a request online with GreenShield +  to check your coverage.

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

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.

If you require any assistance during this process, please contact GreenShield.

For a compound to be eligible with GreenShield, 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

GreenShield will guide you through the eligibility of Compound Drugs.

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

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, GS 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 GreenShield Eligible Criteria Sheet for the prescribed drug. There are three ways to do this:
   • Download the forms from the Drug Coverage Search results on GreenShield+, or
   • Contact GreenShield to request the Prescription Drug Special Authorization Request Form and/or the Eligible Criteria Sheet.
     • By email: drugspecial.autho@greenshield.ca
     • By phone: 1-888-525-7587, "select Option 1" or 1-888-711-1119
     • 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 GreenShield:
   • By email: Scan the document and email to drugspecial.autho@greenshield.ca
   • By mail: GreenShield, Attn: Drug Special Authorization, P.O. Box 1606, Windsor, ON N9A 6W1
   • By fax: 1-866-797-6483

GreenShield along with NKS Assist, have developed a Preferred Pharmacy Network (PPN) to help limit the high cost of specialty drugs for you and your benefits plan and ensures that you get the treatment support you need.

GreenShield’s cross-Canada preferred pharmacy network includes chain pharmacies such as Shoppers Drug Mart, Loblaws, Safeway, Lawton’s Drugs, Sobeys along with NKS Health pharmacies and a few independent pharmacies, mostly in rural or remote areas. Some outpatient pharmacies in select regional cancer centers, which are centers of excellence in the treatment of cancer are also included. In addition, all of the network pharmacies that are part of PPN offer medication delivery to your home or clinic.

The specialty drugs included in the PPN program are available from approved pharmacies at a reduced cost, which may reduce your out-of-pocket expenses. Refer to Preferred Pharmacy Network for further details. 

GreenShield Pharmacy (previously Digital Pharmacy) provides you convenient and affordable access to the medications and pharmacy services you need – from the comfort of your home.

Skip the 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? 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 GreenShield plan members at no additional cost.

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

If you must take the brand name version of a drug due to an adverse reaction to the generic version, your pharmacist or physician will complete a Health Canada adverse drug reaction exception form to be submitted to both GreenShield and Health Canada. 

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 GreenShield for assessment.

Contact GreenShield if you have questions regarding this process.

GreenShield 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 GS 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 GreenShield before your drug claim can be reimbursed. Further, certain drugs defined by GreenShield as specialty drugs may be required to be purchased from an approved pharmacy that is a member of GreenShield’s Specialty Care Program before your claim can be reimbursed.

You can find out if your drug requires prior authorization or is included in GreenShield’s Specialty Care Program, either by checking your coverage under “Your Health Benefits” on GreenShield + or by contacting GreenShield’s Customer Service Centre.

Current State

 For those who are newly starting biologic therapy, GreenShield covers only biosimilars (if one exists) and allows originator products only in exceptional circumstances (i.e. the prescriber must submit a clinical rationale for why the plan member is not able to use a biosimilar product).  

Current member experience: If a member receives a prescription for an originator biologic, the pharmacist will advise that there is no coverage unless approved by GreenShield through prior authorization; alternatively, the member can obtain a prescription for the covered biosimilar.   

What’s changing?

As of October 15, 2024, members who are newly starting treatment with a “low-cost” biologic drug have the option to use either the originator product or a biosimilar alternative. For those who choose the originator product, GreenShield will reimburse up to the cost of the biosimilar and the plan member will be responsible for the difference.  

Member experiences on or after October 15, 2024: If a member receives a prescription for an originator biologic, the pharmacist will advise that there is coverage up to the cost of the biosimilar only (while dispensing the originator biologic); alternatively, they can pursue prior authorization through GreenShield for the originator biologic to determine if exceptional circumstances exist which would allow for full coverage of the originator biologic.   

This change applies to the following low-cost biologics that have biosimilars available: 

If you have any questions regarding the biosimilar new start program, please reach out to GreenShield