Prescription Drugs

The plan covers drugs that require a written prescription, have a drug identification number and are on the Medavie Blue Cross Managed Formulary (this list is subject to change without notice). Prescription Drug Coverage for you and your spouse ceases at age 70. An electronic drug look-up tool is available on the Medavie Blue Cross site or mobile app www.medaviebc.ca/app

For each prescription fill, you pay the dispensing fee up to $492 per family per calendar year, for the lowest priced alternative (typically a generic) drug covered under the managed drug formulary.  Please show your Benefits Card to your pharmacist. If you do not have a card, please contact your employer or Group Benefits Solutions at 1-866-886-7246.

Prescription drugs are the biggest cost for your group plan. We manage the drug costs using the following strategies to support the plan members prescription drug needs and the sustainability of the plan.

Defined drug list: The formulary is made up of a list of clinically-effective and affordable prescription drugs that are used to treat most medical conditions.  For drugs that are not covered by your plan, a suitable alternative can usually be found within the formulary that offer similar, equally-effective medical results and is available at a lower cost.

Prior Authorization: Certain Eligible Drugs require prior or ongoing authorization by Medavie Blue Cross to qualify for reimbursement. The criteria to be met for Prior Authorization is established by Medavie Blue Cross and may include requiring the Participant to participate in a Patient Support Program. The first time you present a prescription for an Eligible Drug on the Prior Authorization list your pharmacist will indicate the need for Prior Authorization. You and your physician must complete a Prior Authorization Prescription Drug Form and submit to Medavie Blue Cross. You will receive confirmation in writing regarding the decision and if approved, this confirmation will include the effective date and duration of your approval.

Mandatory Drug Substitution (Lowest Cost Alternative):  Your plan will pay up to the cost of the lowest-cost alternative, typically the generic drug, even if a brand name medication is dispensed. This means the Medavie Blue Cross Substitution Provision applies and an Interchangeable Drug has been prescribed, Medavie Blue Cross will reimburse to the lowest ingredient cost Interchangeable Drug. In the case of biologic drugs, Medavie Blue Cross reserves the right to reimburse to a less expensive biosimilar drug. Participants may request a higher cost Interchangeable Drug; however, they will be responsible for paying the difference in cost between the Interchangeable Drugs.  For Participants with an adverse reaction to the Interchangeable Drug dispensed, Medavie Blue Cross will consider reimbursement to another Interchangeable Drug on a case by case basis only through the Prior Authorization process.

Step Therapy: For many conditions, such as high blood pressure, diabetes, gout, high cholesterol and depression, there are a number of equally safe and effective treatment options to choose from.  Under Step Therapy, the plan will reimburse the cost of a therapeutic substitution by your pharmacist, making it easier for you to get proven safe and effective treatments in a way that can save money for you and your drug plan.  For more information call the Medavie Blue Cross Customer Information Contact Centre toll-free at 1-800-667-4511. Alternatively, you can email your questions to inquiry@medavie.bluecross.ca or visit our website at www.medaviebc.ca

Exclusions and Limitations

Expenses associated with the following categories of drugs or services are not eligible for reimbursement, even when prescribed:

• injectable and oral vitamins;
• treatments for weight management, including proteins and food or dietary supplements;
• natural health products including homeopathic products, herbal medicines, traditional medicines, nutritional and dietary supplements, unless specifically listed as covered under this benefit;
• hair growth stimulants;
• services, treatment or supplies that:
  • are not Medically Necessary;
  • are for cosmetic purposes only;
  • are elective in nature; or
  • have experimental or investigative indication;
• procedures related to drugs injected by a Health Practitioner or Physician in a private clinic;
• drugs that Medavie Blue Cross determines are intended to be administered in hospital, based on the way they are administered and the condition the drug is used to treat;
• expenses that are covered under any government health care coverage or charges payable under a workers’ compensation board/commission, any automobile insurance bureau or any other similar law or public plan;
• services, treatment or supplies the Participant receives free of charge;
• charges that would not have been incurred if no coverage existed;
• all forms of cannabis; or
• pharmacy services.