Group Benefits Basics and Your Coverage for Prescription Drugs

If you are a full-time permanent employee, a member of a union, an association, or student group then it is likely you have access to group insurance coverage through a plan offered by your employer, union trustees, association, or student group. Not all group insurance coverage is created equal.

Some group insurance plans have comprehensive coverage that includes life, disability, health including prescription drugs, and dental insurance. Other plans, particularly plans offered by voluntary associations, may have more limited options. In this section we will explain the basics of prescription drug coverage and claims payment through group health plans.

Prescription drug insurance coverage is typically included as part of a group health plan. Prescription drug and dental insurance are the two benefits that are claimed the most by plan members, so you probably already know whether you have prescription drug coverage. The list of drugs that are covered is called a drug plan formulary and it can vary between plans.

Requiring drugs to have a prior authorization (PA) is the insurer’s way of managing access to and costs for specialty drugs, which are usually drugs costing $10,000 annually, or more. Prior authorization is in place to ensure that the medication prescribed is medically necessary and cost effective – in other words, either there are no suitable lower-cost alternatives available, or all other lower-cost alternatives have already been explored for the patient. Because the number of specialty drugs is increasing, the prior authorization process will become more commonplace.

Prior authorization is also used by public drug plans funded by provinces who usually refer to it as special authorization or exceptional access. The information on this site is primarily directed towards group insurance plans that include drug coverage that requires a prior authorization process.

The information on this website will also be helpful if you or a member of your family have been prescribed a drug(s) that may be eligible under your provinces public drug formulary. To find out more about whether a speciality drug is eligible for coverage under a private or public drug program anyone can use the Is My Prescription Covered tool developed by the Canadian Skin Patient Alliance.

If you live in a province with public drug coverage, or pharmacare, you may need to submit your prior authorization drug claim to them before your group insurance plan. If the province denies your claim then it can be submitted to your group insurer.

Do You Have Prescription Drug Coverage?

It is important to have information that confirms your coverage before you fill the prescription at the pharmacy. You can find out more a`bout coverage at Is My Prescription Covered? You should also make sure you know your policy and certificate number. This will avoid time consuming delays. Here are some places to check:

Plastic wallet card will have your name and a policy and certificate number
An email confirming your coverage and a summary of the benefits under your plan
Access to an insurer portal through a link to confirm coverage using your policy and certificate number
A hard copy or online booklet or statement of benefits from your employer or the plan sponsor.

If you have looked at this checklist and are still not sure if you have group coverage or coverage that includes prescription drugs, then contact your human resources department where you work, your union representative, your association, or student group. They will be able to help you find the information you need.

If you already know you have prescription drug coverage, you may be covered as a plan member, a spouse of a plan member, or you may have drug coverage under more than one plan. Dependent children may also have drug coverage under one or both parents’ plans. Not all plans are created equal.

If you or your dependents have coverage under more than one plan:

You should first claim under the plan where you are the primary plan member.
If your expenses are not covered under the plan where you are the primary plan member, or if your plan pays less than 100% of your expenses, (usually 80% or 90%), then you can claim what is not covered through your spouse’s drug benefits plan. You are eligible to receive up to 100% reimbursement for eligible drug expenses through your family’s plans combined.
When both parents have plans and their children are covered under both as dependents, the plan of the parent with the earlier birth date in the calendar year pays first. For instance, if Jenn’s birthday is January 5th and she is 37, and Steve’s birthday is November 5th and he is 40, Jenn’s birth date falls first in the calendar year, even though Steve is older. Claims for dependents should be submitted to Jenn’s plan first.
If your dependent’s expenses are not covered under the plan of the parent with the earlier birth date in the calendar year, then their claim can be submitted under the other parent’s plan.

Patient or Patient Group

Group Benefits Basics and Your Coverage for Prescription Drugs

Do You Have Prescription Drug Coverage?