Support Staff Benefits Plan Changes

On January 1, 2016, the Support Staff Benefits Committee (SSBC) introduced several changes to the support staff prescription drug plan. The changes were designed to ensure that prescription drug benefits were delivered to covered members in an efficient, cost-effective manner allowing members and their dependents to receive the right drug at the right cost at the right time.

The following changes were introduced January 1, 2016.

  1. Prior Authorization for Biologic & Specialty Drugs
    • Effective January 1, 2016, reimbursements for biologic and specialty drugs will be subject to the Sun Life Prior Authorization program. The program covers a number of health conditions as referenced on the Sun Life Prior Authorization website
    • Members with prescriptions for prior authorization drugs reimbursed in the 120 days prior to implementation will be grandfathered with individual DIN exceptions for 100% of the cost of the medication covered (subject to the existing plan limitations).
    • Changes to drug treatment protocols will be subject to the Prior Authorization program and require prior authorization.
    • Any member prescribed a biologic or specialty drug covered by the prior authorization program after January 1, 2016 will be required to have their physician complete and submit the appropriate prior authorization form.

  2. DFFL (Dispensing Fee Frequency Limit)
    • Effective January 1, 2016, support staff with prescriptions on the maintenance medications list are covered for a maximum of five (5) dispensing fees per calendar year per certificate for each maintenance medication. Maintenance medications are those used to treat chronic, long-term conditions. If members choose to have prescriptions filled more frequently, only the cost of the drug itself will be covered, subject to any other plan restrictions. 
    • If a drug is defined as acute, it will not be part of the DFFL program and all prescription dispensing fees will be covered.
    • If prescribed medications are only dispensed in less than 90/100 day supplies requiring more than five (5) prescriptions per year, members will be required to complete and submit the Sun Life Drug Exemption form for each affected drug.
    • The University of Alberta will inform members early in the year about the DFFL restriction and the exemption process.

  3. Mandatory Generic Substitution / Lowest Priced Equivalent
    • Effective January 1, 2016, claims for prescription drugs with a generic substitution, including those where “no-substitution” is identified on the prescription, are reimbursed at the rate of the lowest-priced equivalent.   
    • If there is a medically supported reason why an alternative generic drug cannot be used, a member may have their physician complete the Sun Life Drug Exemption form and submit it to Sun Life for review.
    • If a covered member chooses to purchase a brand name drug, the difference between the lowest price generic drug and the brand name will be the member's expense.  

  4. Over-the-counter (OTC) Medications
    • Effective January 1, 2016, reimbursement for over-the-counter (OTC) drug products will not be permitted under the support staff benefit plan.
    • Life sustaining OTCs (such as insulin, diabetic supplies, Epi-Pen) and a small number of non-life sustaining OTCs that are injectable OTCs (i.e. injectable vitamins) are included in the plan and will be covered.
    • No grandfathering will apply to this restriction.

  5. MAC (Maximum Allowable Cost) / Reference Based Pricing
    • Effective January 1, 2016, prescriptions for drugs within the following therapeutic drug classes will be subject to Maximum Allowable Cost pricing.
    • The support staff drug plan applies a maximum dollar amount to the therapeutic class of drugs (Column 2) based on the most cost-effective drug within the class (the reference drug) as shown in Column 4 of Table 1 below.
    • Prescriptions for drugs within these classes (Column 3) are reimbursed at the maximum allowable cost. Members do not have to be prescribed an alternative drug within the MAC program to be reimbursed at the maximum allowable cost.
    • Members with prescriptions for drugs in these therapeutic drug classes that were reimbursed in the 120 days prior to January 1, 2016 will not be automatically grandfathered. 
    • MAC pricing applies to all drug claims in the five therapeutic drug classes listed in Table 1.
    • Exceptions to the MAC pricing are permitted only if the member can provide a physician's medical evidence that the MAC drug cannot be used. The Sun Life Drug Exemption form must be completed and submitted for review in that case. Members will only be reimbursed for the maximum allowable price of the drugs listed within Column 4 unless an exception is approved.

Table 1

Health Condition

Therapeutic Drug Class

Specific Drug (including generics above MAC)

Drugs within MAC

High blood pressure

Angiotensin coverting enzyme inhibitors

Mavik (Trandolarpril)

Accupril (Quinapril)

Conversyl (Perindopril)

Monopril (Fosinopril)

Vasotec (Enalpril)

Inhibace (Cilazapril)

Lotensin (Benazepril) 

Altace (Ramipril)

Zestril, Prinivil (Lisinopril)

High blood pressure

Angiotensis II receptor blockers

Cozaar (Losartan)

Olmetec (Olemesartan)

Teveten (Eprosartan)

Avapro (Irbesartan)

Edarbi (Azilsartan)

Diovan (Valsartan)

Atacant (Candesartan)

Micardis (Telmisartan)

High blood pressure

Dihydropyridine calcium channel blockers

Plendil, Renedil (Felodipine)

Adalat XL (Nifedipine)

Norvasc (Amlodipine)

Cholesterol

HMG-CoA reductase inhibitors

Lipitor (Atorvastatin)

Zocor (Simvastatin)

Mevacor (Lovastatin)

Pravachol (Pravastatin)

Lescol (Fluvastatin)

Crestor (Rosuvastatin)

Stomach Hyperacidity

Proton pump inhibitors

Pantoloc (Pantaprazole sodium)

Dexilant (Dexlansoprazole)

Prevacid (Lansoprazole)

Losec (Omeprazole)

Tecta (Pantoprazole magnesium)

Pariet (Rabeprazole)

 

Update April 1, 2016

Beginning April 1, 2016, the national prescription drug formulary restrictions that were implemented January 1 were removed from the support staff prescription drug plan. The national formulary restricted the number of prescription drugs that were covered by the plan and unintentionally required members to pay out-of-pocket for drugs not intended to be restricted. Members that submitted claims for restricted drugs who were not prescribed and reimbursed for an alternative or generic treatment by either the University drug plan or an alternative plan should contact Sun Life to discuss the claim.

The restrictions identified above in section 1 to 5 remain in effect for the Support Staff Benefits plan.

Using Sun Life's Drug Inquiry Tool

Sun Life's drug inquiry tool is currently provided to all plan members. It will indicate which products are preferred products. Having this information will support individuals in conversations with their treating physicians and dispensing pharmacists.

Using your Health Spending Account to Cover Additional Costs

The Health Spending Account (HSA) is used to pay for eligible medical and dental expenses beyond those covered by the Supplementary Health Care and Dental Care plans. Support staff that may be impacted by the drug plan changes may wish to allocate more funds to the HSA account to cover anticipated prescription drug costs. For more information on the HSA, please visit the HSA webpage.