Prescription drug coverage

Your coverage, your choice
With a change in the Acute/Maintenance/Specialty formulary, this plan design is more flexible than ever. Instead of having specialty medications fixed at 100 percent coverage, you can now set your own coverage for each type of drug.

Whether you allocate 60 percent for acute drugs and 80 percent for specialty drugs or 70 percent for maintenance drugs and 50 percent for acute drugs, this plan design offers you the freedom to choose based on your specific needs.

Dispense fee frequency limit Implementing a dispense fee frequency limit offers coverage for a maximum number of dispense fees per maintenance drug, and is only applicable to maintenance medications. This limit encourages plan members to request a 3-month (rather than 1-month) supply of their medication, which can reduce dispense fee cost by 75 percent per year.

Generic Medications Formulary for Selectpac members
Our Selectpac plan coverage now offers access to the Generic Medications Formulary, limiting coverage to generic drugs only. This coverage must be used as part of a 2-tier plan design.

Coordination of benefits Traditionally, second-payer drug claims were reimbursed up to the pharmacy’s submitted amount. We’re now using the price list of TELUS Health to determine how to coordinate benefits drug claims up to the reasonable and customary amount.

For more information, contact your Great-West Life group representative.  

New cholesterol drugs can be expensive. We can help your plan members get access to the medication they need while managing the cost of your plan.

High cholesterol can lead to heart disease and stroke, the number one cause of hospitalization and death in Canada. One of the most recently released drugs known as PCSK9 inhibitors have had positive effects on patients who don’t respond well to other traditional treatments – but they come with a high price tag.

What are PCSK9 inhibitors? PCSK9 inhibitors are injectable biologics that help lower cholesterols in patients who haven’t responded well to traditional statin therapy, like Lipitor. Repatha is a PCSK9 inhibitor and can lower bad cholesterol by 60 percent in patients, but can also have them paying around $7800 per year.

Our 3-step prior authorization process Our process provides an effective approach to managing claims for certain prescription drugs.

1. Pre-approval monitoring: Our pharmacy services team determines which drugs can be considered for our Prior Authorization program, moving them into our early screening process after they’re approved by Health Canada.

2. Early screening: Once drugs are approved by Health Canada, we flag new drugs to make sure claims are not being paid while a comprehensive assessment is being conducted. Our Prescription Drug Governance Committee completes the assessment and reviews the data provided by Health Canada. If we receive a request for coverage before the review process is complete, a health care professional will assess it on a case-by-case basis.

3. Decision: If our Prescription Drug Governance Committee decides to include the drug in our Prior Authorization program, we determine if it will also be added to one of our DrugSolutions programs:

• Health Case Management – one-on-one support for patients
• Designated Pharmacy – an extensive network of Canadian pharmacies delivering high-quality dispensing services at preferred vendors
  

If a drug is added to this program, we develop a customized prior authorization form based on some of the most rigorous criteria in the industry. You can be confident that:

• Your plan members have access to the medication they need to help maintain their health and productivity.
• Plan costs are managed by approving claims only when specific criteria is met.
  

For more information, contact your Great-West Life group representative.  

What is Therapeutic Class Pricing (TCP)? Designed to help keep the cost of drug plans affordable, Therapeutic Class Pricing sets reimbursement limits for medications in specific drug classes.

There can be many medications in each drug class that vary in price, but that are prescribed to treat the same medical condition. In each class, a drug that proves to provide effective treatment is classified as a “reference drug.”

We consider several factors when determining a reference drug, including clinical studies, safety data, utilization, approved indications, expert opinion and cost.

5 TCP drug classes

• To treat stomach acid:
  
  • Proton Pump Inhibitors (PPI)
     
• To treat high cholesterol: 
  • HMG-CoA Reductase Inhibitors (Statins)
     
• To treat high blood pressure: 
  • Angiotensin Converting Enzyme Inhibitors (ACEI)
  • Angiotensin Receptor Blockers (ARB)
  • Dihydropyridine Calcium Channel Blockers (CCB)

How it works
If a plan member is prescribed Medication A (a reference drug), they’ll be reimbursed based on the plan design.

If a plan member is prescribed Medication B, they can:

• Fill the prescription and get reimbursed up to the cost of Medication A and pay the difference out of pocket.
• Ask their doctor to issue a prescription for Medication A instead. In some provinces, pharmacists may be able to adapt the prescription to Medication A.
  

While TCP is designed to help control the cost of drugs, it’s not intended to determine the most appropriate treatment. Plan members should talk to their care providers to choose their best course of action.

For more information, contact your Great-West Life group representative.