Prescription Drugs

Prescription drugs are covered under the Supplementary Health Care Plan. Coverage is limited to drugs which are available by law only on the written order (prescription) of a Physician or Practitioner and dispensed by a licensed pharmacist. Coverage includes the following:

  • Vaccines and influenza shots, including the cost of administration of the injection.
  • Varicose vein injections where medically necessary, including the cost of the administration of the injection.
  • Drugs for the treatment of Erectile Dysfunction will be limited to a maximum of $1200 per Insured per Year.
  • Prescribed contraceptive devices such as an IUD or patch, including cost of administration of device.
  • Medical marijuana purchased from either Health Canada or a designated producer subject to the Marijuana Medical Access regulations.
  • Medication and dietary supplements which are available over the counter without a prescription are not covered.
  • 100% of eligible drug expenses subject to the plan provisions outlined below.

Effective 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. Dispensing Fees & Dispensing Fee Frequency Limit (DFFL)
    • A three-month supply of prescription drug purchases may be dispensed at one time. 
    • Maximum dispensing fee of $8.00 per prescription. The dispensing fees charged by pharmacies vary among providers. You may wish to look for a pharmacy that is willing to charge only one dispensing fee if you are purchasing a three month supply of a drug, or if they are not in a position to fill the entire requirement of the prescription at once. Should the dispensing fees exceed the maximum allowable you will be responsible to pay the difference directly at the time of purchase. Dispensing fees are an eligible expense for the health spending account.
    • 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.

  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.

Pay-Direct Card

Accepted at pharmacies across Canada, your Sun Life Pay-Direct Drug Card can be used for your prescription drug claims covered by your plan.

The Sun Life Pay-Direct program connects you to a network that tracks your drug purchases, allowing your pharmacist to warn you about duplicate medications, early refills and potential drug interactions.

If you need an additional Sun Life Pay-Direct Drug Card (e.g. for a dependent child or student) or misplace your own card, you can download and print a replacement (paper) Pay-Direct drug card from the password-protected Sun Life Member Services Website. Paper cards are accepted at all pharmacies.

If you have any trouble using your card, please contact the Sun Life Customer Care Centre between 7:00 am and 8:00 pm (EST), Monday to Friday at 1 (800) 361-6212.