NOTE: This information is only current as of Jul 21, 2017. Please visit asebp.ca for the most up-to-date information.

Drugs

ASEBP offers comprehensive drug coverage for all benefit plans and reimbursement rates are based on reasonable and customary costs as outlined in the ASEBP Drug Benefit List. Here are the basic eligibility criteria for prescription drugs:

  • Prescribed by a doctor or other licensed health care provider in Canada
  • Dispensed by a licensed pharmacist
  • Purchased in Canada and while you or your dependants are covered under the plan
  • Being used for their intended purpose as defined by Health Canada

You can find your plan number under Coverage on My ASEBP or on your ASEBP ID card on the My ASEBP Mobile App under Extended Health Care.

Note that the following is an interpretation of the official, legally binding ASEBP insurance policies and plan documents available through your employer or by contacting us.

What's covered?

Prescription Drugs

The per cent of coverage applies to the brand or generic, least-cost alternative, preferred alternative or Therapeutic Alternative Reference Price (TARP), depending on the drug. See the Drug Inquiry Tool on My ASEBP for eligibility details on specific drugs.

Plan 1 Plan 2 Plan 3 Plan 5
100% 80% 80% 90%

 

Dispensing Fee Maximums

Dispensing fees are charged by the pharmacy to prepare your medication and can vary between pharmacies. Maximums are a flat rate and are included in the total cost of the prescription. See Pharmacy Dispensing Fees and Compound Drugs for details. 

Plan 1 Plan 2 Plan 3 Plan 5
$9 for drugs and prepackaged compounds $13.50 for compounds $9 for drugs and prepackaged compounds $13.50 for compounds $9 for drugs and prepackaged compounds $13.50 for compounds $9 for drugs and prepackaged compounds $13.50 for compounds

Dispensing for Maintenance Medications

Maintenance medications are drugs prescribed to patients with chronic health conditions or prescriptions that can be managed on a long term basis. See Maintenance Medication Program for details and a complete list of drug classes considered maintenance medications by ASEBP. See the Drug Inquiry Tool on My ASEBP to determine if a specific drug is listed as a maintenance medication.

Plan 1 Plan 2 Plan 3 Plan 5
5 refills per calendar year (January to December) 5 refills per calendar year (January to December) 5 refills per calendar year (January to December) 5 refills per calendar year (January to December)

Smoking Cessation

See the Drug Inquiry Tool on My ASEBP for eligibility details on specific drugs.

Plan 1 Plan 2 Plan 3 Plan 5
100% to a combined lifetime maximum of $500 per person 80% to a combined lifetime maximum of $500 per person 80% to a combined lifetime maximum of $500 per person 90% to a combined lifetime maximum of $500 per person

Infertility Drugs

See the Drug Inquiry Tool on My ASEBP for eligibility details on specific drugs.

Plan 1 Plan 2 Plan 3 Plan 5
$800 per person per calendar year (January to December) $600 per person per calendar year (January to December) $600 per person per calendar year (January to December) $720 per person per calendar year (January to December)

Erectile Dysfunction Drugs

See the Drug Inquiry Tool on My ASEBP for eligibility details on specific drugs.

Plan 1 Plan 2 Plan 3 Plan 5
$100 per person per month to a yearly maximum of $800 $100 per person per month to a yearly maximum of $800 $100 per person per month to a yearly maximum of $800 $100 per person per month to a yearly maximum of $800

Vaccines

Your plan includes coverage for particular preventative and travel vaccines. Be sure to access your provincial health care insurance plan or other government programs that offer free or subsidized vaccines (e.g. flu vaccine) prior to submitting a claim. See the Drug Inquiry Tool on My ASEBP for eligibility details on specific vaccines.

Plan 1 Plan 2 Plan 3 Plan 5
100% 80% 80% 90%

Joint Injectable Materials

Your plan covers these materials only if they are required to treat osteoarthritis and they must be pre-approved by ASEBP prior to purchase. Please contact us for pre-approval requirements.

Plan 1 Plan 2 Plan 3 Plan 5
$1,000 per person per calendar year (January to December) $1,000 per person per calendar year (January to December) $1,000 per person per calendar year (January to December) $1,000 per person per calendar year (January to December)

 

Over-the-Counter Life-Sustaining Drugs

Some examples of over-the-counter life-sustaining drugs include injectable epinephrine, insulin, injectable glucagon kits, injectable sclerotherapy products, nitroglycerin rescue treatments and potassium supplements.

Plan 1 Plan 2 Plan 3 Plan 5
100% 80% 80% 90%

Sclerotherapy

Your plan includes the cost of drugs used for procedures to treat varicose and spider veins. See the Drug Inquiry Tool on My ASEBP for eligibility details on specific drugs.

Plan 1 Plan 2 Plan 3 Plan 5
100% 80% 80% 90%

What's not covered?

Only drug products or supplies specifically listed as covered in the Drug Inquiry Tool may be reimbursed and are subject to any limitations, maximums or exclusions as indicated. The following are a number of products and/or services not covered under the plan. Note that this list is not exhaustive. 

  • Experimental drugs
  • Drugs not approved by Health Canada
  • Vitamins, minerals or herbal drugs
  • Early refills for drugs without any extenuating circumstances
  • Over-the-counter drugs that are not life-sustaining (e.g. low dose aspirin)
  • Treatment that is experimental, educational or for the purpose of research
  • Treatment provided free of charge
  • Non-emergent drugs purchased outside Canada
  • Expenses covered through a government program, whether or not you or your dependants choose to participate in the program
  • Medical services and supplies provided by a dental or medical department in which there is a conflict of interest (e.g. maintained by the employer, a mutual benefit association, labour union, trustee or similar type of group)
  • Expenses incurred while on active duty in any military or peacekeeping force
  • All coverage where your conduct would constitute an indictable offence within Canada

Additional Information

Brand and Generic Drugs

Brand drugs are patented and manufactured by a pharmaceutical company under a particular name. Generic drugs are essentially copies of brand name drugs. They have the same dosage, strength, delivery method (e.g. oral, intravenous, etc.), quality, performance and intended use. In most cases, generic drugs become available after the patent for the original manufacturer of the brand expires.

Early Refills

A prescription refill is considered early at any time prior to 70 per cent of an existing prescription being used. So, if you have a 90-day prescription, you’d have to be at least 63 days into it before you will be eligible for a refill. Let your pharmacist know if you have extenuating circumstances (e.g. your medication was lost or stolen) as pharmacies can make allowances. 

Early Refills for Travel

Before you leave on a trip outside of Canada, you should refill any prescriptions you may need while you’re away. If you need more than a 100-day supply of your prescription, you’ll need to use the Greater than 100 Day Supply of Prescription Drugs Request prior to visiting your pharmacy.

Least Cost Alternative (LCA)

The coverage level for many prescription drugs is based on the Least Cost Alternative—the lowest cost brand or generic drug alternative to what was prescribed by your health care provider. The LCA must have the same dosage, strength, delivery method (e.g. oral, intravenous, etc.), quality, performance and intended use to what you were prescribed.

Maintenance Medication Program

Drugs prescribed to patients with chronic health conditions or prescriptions that can be managed on a long term basis are considered maintenance medications. As these drugs are usually taken continuously over a long period of time, there is a low likelihood that the dosage will change.

ASEBP’s Maintenance Medication Program considers drugs in the following nine classes maintenance medications. Drugs within these classes have a maximum of five dispensing fees (the amount your pharmacy charges to fill your prescription) allowed within a calendar year (January 1 – December 31). This encourages you to fill a three-month’s supply of your medication at one time—lessening the risk of missing doses between fills—and gives you a safe, simple and affordable way to help keep the plan comprehensive and sustainable over the long term.

  1. Anti-hypertensive agents (used to treat high blood pressure)
  2. Anti-depressants
  3. Anti-hyperlipidemic agents (used to treat high cholesterol)
  4. Anti-diabetic agents
  5. Contraceptives
  6. Thyroid agents (used to treat abnormal thyroid function)
  7. Anti-asthmatics/Chronic Obstructive Pulmonary Disease (COPD)
  8. Hormone replacement therapy
  9. Medications for overactive bladder

If you choose to have your prescription for a maintenance drug filled more than five times during the year, you will be responsible to pay the entire dispensing fee portion of the total prescription cost out-of-pocket after the fifth fill (the drug portion will continue to be covered by your plan). In some circumstances your prescription won’t allow for a three months’ supply (e.g. blister packaging and/or other medical reasons). In these cases, your pharmacist will be able to help you to obtain any required approvals. Your pharmacy is notified that you have a limited number of dispensing fees for that drug per calendar year and will be able to tell you how many refills you have before you’re responsible to pay the entire dispensing fee.

Visit the Drug Inquiry Tool on My ASEBP to see if a drug you’ve been prescribed falls within the Maintenance Medication Program.

Pharmacy Dispensing Fees and Compound Drugs

Pharmacies will typically charge a dispensing fee for preparing your medication. The amount they charge varies between pharmacies, and ASEBP sets limits (see below) on the amount that can be reimbursed per dispense. You are responsible to cover any difference in the fee charged by the pharmacy and what ASEBP has set for the maximum.

  1. $9 for drugs and prepackaged compounds
  2. $13.50 for compounds made in a dispensing pharmacy

Compounds are a mixture of one or more drug ingredients prepared by the pharmacist when you pick up your prescription. Prepackaged compounds come to the pharmacy from another compounding pharmacy already assembled. It’s important to note that all drug ingredients in the compound must be eligible under the plan for the drug to be eligible for coverage.

Preferred Alternative

Preferred alternatives are drugs preferred by ASEBP because they provide better value with similar safety and effectiveness as other drugs used to treat the same health conditions.

Visit the Drug Inquiry Tool on My ASEBP to see if a drug you’ve been prescribed has preferred alternatives.

Special Authorization

Some drugs require special authorization or a review to be eligible for coverage. If your pharmacist has told you that your prescription requires special authorization, you will likely either:

  1. be asked to go back to your doctor or other licensed health care provider who wrote you the prescription to complete a form (they have easy access to this form), or
  2. be assisted by your pharmacist in contacting your doctor or other licensed health care provider who wrote you the prescription to complete the form. You and your doctor will be notified once a decision is reached on whether or not the drug will be covered. 

Your pharmacist will be able to tell you if your authorization is due to renew, but generally you won’t be responsible for initiating the renewal. Keep in mind that over-the-counter products and specific brands of interchangeable drugs are not eligible for special authorization. 

Visit the Drug Inquiry Tool on My ASEBP to see if a drug you’ve been prescribed requires special authorization.

Enhanced Special Authorization

There is a different authorization process for specialty drugs used to treat the following five health conditions:

  1. Chronic hepatitis C
  2. Crohn’s disease/colitis
  3. Multiple sclerosis
  4. Psoriasis
  5. Rheumatoid arthritis

This process ensures physicians escalate therapies for these five health conditions in a safe, gradual and cost-effective way. Our focus on the health conditions allows us to better see all aspects of our covered members’ health experiences and positions us to support them using all the health care tools, benefits and resources available through the plan.

New prescriptions

If you have a new prescription for a drug used to treat one of the health conditions above, and the Drug Inquiry Tool on My ASEBP indicates it requires an enhanced special authorization to be eligible for coverage, please follow the steps below:

  1. Discuss treatment options with your specialist.
  2. Download the form that applies to your condition.
  3. Complete and sign the patient section of the form (Part 1).
  4. Provide the form to your specialist. They will complete their section of the form and submit to us.
  5. We will advise you and your specialist whether or not the drug will be covered. 

Here’s some important information for you to know:

  • Doctors or support groups may provide you complimentary doses of a specialty drug to take before you get approval that the drug will be covered. Be advised that simply taking the drug is not a guarantee of coverage approval and that some specialty drugs are not easy to stop taking. So, if you start a course of treatment before receiving enhanced special authorization approval from us, there is a chance that coverage will not be approved and you will be responsible for the cost.
  • If the drug you’ve been prescribed says it requires enhanced special authorization on the Drug Inquiry Tool on My ASEBP but you’re not taking it for one of the five conditions listed above (e.g. ankylosing spondylitis, psoriatic arthritis, cancer, hemophilia, etc.), you are not required to apply for enhanced special authorization. Your doctor will manage this process for you.

Renewing your Enhanced Special Authorization

You’ll have to renew your application for enhanced special authorization approval annually. Please follow the steps below to renew:

  1. Once you receive notification that your enhanced special authorization is due to renew, download the form that applies to your condition.
  2. Complete and sign the patient section of the form (Part 1, sections A & B only).
  3. Provide the form to your specialist. They will complete the form (Part 2, sections A & F only) and submit to us.
  4. We will advise you and your specialist whether or not the renewal is approved and the drug will continue to be covered. 

Here’s some important information for you to know:

  • If there has been more than 120 days where you didn’t take the drug (e.g. surgery or pregnancy prevented you from taking it or another benefit plan paid the claim), your specialist will need to explain the reason on their portion of the form.
  • Chronic hepatitis C is not eligible for renewal as it is a one-time treatment.
  • If you haven’t already, please register with My ASEBP using your personal email address (instead of your work email). This way, you will receive important information on the status of your enhanced special authorization by email. 
     

Step Therapy Program

The Step Therapy Program promotes the use of what we call "first-line" drugs for select medications used to treat overactive bladder, asthma and diabetes/blood sugar management. Considered less invasive than "second-line" drugs, first-line drugs also cost less. Within this program, you will need to show that you have tried the first-line drug before the second-line drug will be available for coverage. If the first-line drugs were not effective, caused adverse reactions or you have a medical condition that may have a negative interaction, the second-line drugs will be eligible for you. In these cases, a special authorization is required. 

Visit the Drug Inquiry Tool on My ASEBP to see if a drug you’ve been prescribed is included in the Step Therapy Program.

Therapeutic Alternative Reference Pricing (TARP)

ASEBP’s Therapeutic Alternative Reference Pricing (TARP) program encourages cost effective prescribing for four common medical conditions. The program identifies “preferred” drugs to treat the following:

  1. Stomach hyperacidity
  2. High blood pressure
  3. Pain/inflammation management (non-narcotic)
  4. Migraines

All the medications identified as preferred alternatives have similar active ingredients to their brand or generic counterparts and are proven equally safe and effective. You can visit the Drug Inquiry Tool on My ASEBP to see if a drug you’ve been prescribed has preferred alternatives under the TARP program.

If the drug you’ve been prescribed falls into one of the four categories listed above and has preferred alternatives, you have two options:

  1. You can choose to start taking the preferred drug instead of the one you were prescribed and you’ll be covered as you would usually under your plan, or
  2. You can choose to start taking or remain on the drug you were originally prescribed and pay for the cost difference between the prescribed and the preferred drug either out-of-pocket, through your benefits with another health care provider or through a Spending Account if you have access to one.

If you can’t take the preferred drug for medical reasons (e.g. you have an allergy), the doctor or other licensed health care provider who wrote the prescription can submit a special (pricing) authorization request on your behalf—they have easy access to the required form. If approved, this authorization will ensure you’re covered for the prescribed drug within the limits of your plan.

If you choose to remain on your prescribed drug, pay out-of-pocket for the difference and then have your health care provider submit a special authorization to ASEBP for review afterwards, understand that:

  1. The submission of the authorization is not a guarantee of approval, and
  2. If approved, the authorization takes effect on the first day of the month that your approval was granted and not the date you filled your prescription or made the claim.