Drugs and allergy sera (except vaccinations) that legally require a medical doctor’s prescription (including contraceptive drugs that are prescribed by a doctor to treat a medical condition), whether provided by a doctor or purchased from a pharmacy, are covered. Some vaccinations are covered if they are required as a condition of employment. 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. If in doubt, you should ask your doctor or your pharmacist for confirmation if a certain drug can be obtained without a prescription.
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 anti-obesity drugs are covered.
Some drugs have dollar limits. There is a $300 annual limit for drugs to treat erectile dysfunction. Fertility drugs are limited to a 12 month supply and a lifetime maximum of $12,000. Smoking cessation drugs require a prescription and have a lifetime maximum benefit of $300.
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).
Effective July 1, 2017 the Shingles Vaccine will be an eligible expense for active and retired members and their dependents aged 60 – 80 years, with a life-time maximum reimbursement of $150.00 per individual. OHIP provides coverage for the shingles vaccine to Ontario residents aged 65 to 70.
The Ontario Drug Benefit Program (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 (or your spouse’s drugs, if your spouse is aged 65 or over).The Local 46 Drug Plan does not cover deductibles or dispensing fees payable under the ODB.
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.
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.
Smoking cessation devices or drugs which require a prescription, up to a lifetime maximum of $300.
Drugs must be dispensed by a provider approved by the Trustees on the advice of Medavie Blue Cross.
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 and Medavie Blue Cross.
- 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 to WSIB (the Workplace Safety Insurance Board).