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Drug Benefits

COVERED EXPENSES

The purpose of our Drug Plan is to help pay for the cost of prescription drugs not covered the Ontario Drug Benefit Program (ODB). ODB is available through OHIP to residents of Ontario aged 65 and over. If you qualify, ODB will in most cases pay for your drugs (and your spouse’s drugs, if your spouse is over age 65).Please note that the Local 46 Drug Plan does not cover any deductibles or dispensing fees required to be paid under the Ontario Drug Benefit Program.

All other drugs and allergy sera that legally require a medical doctor’s prescription, except vaccinations and contraceptives (unless medically necessary), whether provided by a doctor or purchased from a pharmacy, are covered. Certain drugs prescribed by dentists or other qualified health professionals will be considered if the professional is allowed by law to prescribe those drugs.

Only drugs which require a prescription by law and that are approved by MBC will be covered. As some drugs prescribed by doctors can also be purchased over the counter, it is important to note that these drugs are not payable under the Plan, except for those prescribed for life threatening conditions. If in doubt, you should ask your doctor or your pharmacist for confirmation if a certain drug can be obtained without a prescription. Some anti-obesity drugs are covered.

The Plan pays 100% of the dispensing fee to a maximum of $8.50 and 90% of the ingredient cost of the drug. You may choose any pharmacy but the Plan will only cover dispensing fees up to $8.50. Certain drugs require pre-authorization and approval by Medavie Blue Cross. Drugs whose annual cost is likely to be $5,000 or more require pre-authorization and are reimbursed at 50%. Some other drugs have dollar limits. There is a $300 annual limit for drugs to treat erectile dysfunction. Smoking cessation drugs require a prescription and have a $300 lifetime maximum.

In the case of a drug administered by injection, have the doctor show the actual cost of the drug separate from his fee for performing the injection. (The Plan pays 90% of the cost of the drug and OHIP pays for the doctor’s services).

From time to time certain drugs are removed from the list of drugs that legally require prescriptions. When this occurs, the drug will no longer be covered by the Plan. To determine whether a drug requires a prescription reference is made to the Compendium of Pharmaceuticals and Specialties issued by the Canadian Pharmaceutical Association as prescribed by the Food and Drug Act of Canada.

The Plan may cover certain drugs which do not require a prescription when prescribed by an attending physician to treat a life threatening illness, provided they are listed in the current Compendium of Pharmaceuticals and Specialties.

Drugs must be dispensed by a provider approved by Trustees and MBC.


Expenses not reimbursed by the Plan

Expenses for the following products or drugs are not covered by the Plan:

  • Products for the care of contact lenses.
  • Proteins or dietary supplements, amino acids, essential fatty acids. Food or food products, and processed or prepared food for infants. Hygiene products and disinfectants including soaps and emollients. Hair care and skin products, and protective substances for the skin. Minerals, vitamins and homeopathic or naturopathic products.
  • Drugs or drug formats or preparations with no therapeutic indication. Herbal remedies, traditional medicines and probiotics.
  • Vaccines unless required as a condition of employment. Contraceptive devices and acne therapy.
  • Laxatives and antacids, antihistamines or other allergy medication.
  • Any single purchase of drugs which would not be used in a 90-day period.
  • Any drug or item that does not have a drug identification number as required by Section 5 Division 1 of the Food and Drugs Act, Canada.
  • All other products not approved by the Trustees with MBC’s advice.
  • Medical services, supplies and drugs to treat injuries or illnesses arising from an accident involving a motor vehicle are not covered by the Plan. They should be submitted to the insurance company that provided the motor vehicle insurance policy. Medical services, supplies and drugs to treat injuries or illnesses sustained at work must be submitted Workplace Safety Insurance Board.

DEPENDENTS ARE DEFINED AS:

  • your legal or common-law spouse, and
  • your unmarried children under the age of 21 years, and
  • your unmarried children aged 21 and over who were continuously covered under the Plan and who are full time students and under the age of 26 years or who are unable to support themselves because of mental or physical handicap, but excluding any children who are not financially dependent on you or a handicapped or unmarried child who was not covered under the Plan up to his or her 21st birthday.Your common-law spouse and dependents are only eligible six months after notice of cohabitation is received by the Benefits Office.

For coverage purposes you and your dependents are deemed to be covered under the Hospital and Health Insurance Acts in your province of residence. For Quebec residents, all aspects of RAMQ, the Act respecting prescription drug insurance, relating to drug coverage, including the Act’s provisions regarding maximum coinsurance, out-of-pocket maximums, eligible drugs and exception drugs will be considered part of this Plan.