Drugs
The Alberta School Employee Benefit Plan (ASEBP) offers comprehensive drug coverage for all benefit plans. 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 Canadian pharmacy
- 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 details under Coverage on My ASEBP or on your ASEBP ID card on the My ASEBP Mobile App under Extended Health Care.
Note: the following is a comprehensive summary of the official, legally binding ASEBP insurance policies and plan documents, which are available through your employer or by contacting us.
What's covered?
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. You are responsible to cover any difference in the fee charged by the pharmacy and what ASEBP has set for the maximum. See Pharmacy Dispensing Fees and Compound Drugs for details.
Plans 1, 2, 3, 5
- $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.
If you refill a prescription beyond the allocated five refills per year, this may result in out-of-pocket expenses for you. If you have Spending Account coverage, your out-of-pocket expenses may be eligible. See Spending Accounts for details.
See the Drug Inquiry Tool on My ASEBP to determine if a specific drug is listed as a maintenance medication.
Plans 1, 2, 3, 5
- 5 refills per prescription per calendar year (January to December)
Fertility Drugs
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 maximum of $800 per person per calendar year (January to December) |
80% to a maximum of $600 per person per calendar year (January to December) |
80% to a maximum of $600 per person per calendar year (January to December) |
90% to a maximum of $720 per person per calendar year (January to December) |
Life-Sustaining Over-the-Counter Exceptions List
ASEBP created a defined Life-Sustaining over-the-counter exceptions list for urgently needed, life-sustaining situations because we are required to limit coverage to medically exempt tax benefits. These categories include injectable epinephrine, insulin, injectable glucagon kits, nitroglycerin rescue treatments and potassium supplements.
| Plan 1 | Plan 2 | Plan 3 | Plan 5 |
|---|---|---|---|
| 100% | 80% | 80% | 90% |
Migraine Medications
Approval of migraine medications, including Botox, Emgality and Aimovigis, are subject to Alberta Blue Cross Special Authorization criteria. Patients must request that their specialist (i.e. neurologist) complete the Special Authorization form and submit it directly to Alberta Blue Cross for review and approval. ASEBP doesn’t need to review or receive copies of Special Authorization forms. 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% |
Prescription Drugs
The per cent of coverage applies to the brand or generic preferred alternative or Therapeutic Alternative Reference Price (TARP), depending on the drug. Our plans do not have deductibles. There are maximums on the following categories of prescription drugs: smoking cessation, fertility, and sexual dysfunction medications. 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% |
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% |
Sexual 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% to a yearly maximum of $800 | 80% to a yearly maximum of $800 | 80% to a yearly maximum of $800 | 90% to a yearly maximum of $800 |
Smoking Cessation
See the Drug Inquiry Tool on My ASEBP for eligibility details on specific prescription drugs. Your Employee and Family Assistance Program (EFAP) provides free smoking cessation support. You can also visit Alberta Quits for additional support.
| Plan 1 | Plan 2 | Plan 3 | Plan 5 |
|---|---|---|---|
| 100% to a combined lifetime maximum of $1,500 per person | 80% to a combined lifetime maximum of $1,500 per person | 80% to a combined lifetime maximum of $1,500 per person | 90% to a combined lifetime maximum of $1,500 per person |
Vaccines
Your plan includes coverage for specific 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% |
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 or indications of use that are not approved by Health Canada
- Vitamins, minerals, herbal drugs or homeotherapy remedies
- Over-the-counter drugs that are not on the life-sustaining over-the-counter exceptions list (e.g. low dose aspirin)
- Administration fees for drugs such as Botox and joint injectables
- Early refills for drugs without any extenuating circumstances
- 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
Advisories
Health Canada advisories are available on their website.
Biosimilar Drugs
Biosimilar drugs are cost-effective, “highly similar” copies of brand-name biological drugs whose patents have expired. Health Canada reviews and approves biosimilars to ensure their safety and effectiveness.
The Alberta government’s Biosimilars Initiative requires the replacement of some brand name drugs with biosimilar drugs, when possible. This required change only applies if adult patients (those over 18 and not pregnant) have coverage under an Alberta government-sponsored drug plan.
This change won’t affect your ASEBP benefits, at this time; however, if you have coverage under multiple plans, we encourage you to check what changes, if any, your other service provider may implement now or in the future. Other service providers are developing biosimilar strategies that may not align with ASEBP coverage, so it is important for ASEBP members to be well-informed when using biological products to maximize coverage.
Visit the Government of Alberta’s Biosimilars Initiative for more 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. 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 your province of residence, you should refill any prescriptions you may need while you’re away. If you need more than a 100-day supply of your prescription, or more than a 30-day supply of select high-cost special authorization drugs, you’ll need to use the Travel Supply of Prescription Drugs Request prior to visiting your pharmacy.
Generic Alternative Pricing
The coverage level for many prescription drugs is based on the generic alternative—the lowest cost brand or generic drug alternative to what was prescribed by your health care provider. The generic alternative must have the same dosage, strength, delivery method (e.g. oral, intravenous, etc.), quality, performance and intended use for what you were prescribed.
If you choose to fill the prescription, which is not the lowest-cost brand or generic drug alternative, this may result in out-of-pocket expenses for you. If you have Spending Account coverage, your out-of-pocket expenses may be eligible. See Spending Accounts for details.
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 of 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-months 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.
- High blood pressure medications
- Mood-elevating medications (anti-depressants)
- High cholesterol medications
- High blood sugar medications
- Birth control medications
- Abnormal thyroid medications
- Asthma or Chronic Obstructive Pulmonary Disease (COPD) medications
- Hormone replacement medications
- Overactive bladder medications
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.
- $9 for drugs and prepackaged compounds
- $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. The compound cannot duplicate a commercially available prepackage medication.
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:
- be asked to go back to the doctor or other licensed health care provider who wrote you the prescription to have them complete a special authorization form (they will select the appropriate request form), or
- be assisted by your pharmacist in contacting the doctor or other licensed health care provider who wrote you the prescription to have them complete the request form.
You and the doctor who submitted the request will be notified once a decision is reached on whether or not the prescribed drug will be covered. Special authorization decisions will be available under the Documents tab in your My ASEBP account. My ASEBP users will receive an email when a new decision letter has been posted.
Approved Special Authorization requests follow our normal drug plan coverages. Reimbursement levels will vary based on the plan you are enrolled in.
Please consult with your pharmacist and health care provider regarding requirements for ongoing renewals. Keep in mind that over-the-counter products and specific brands of interchangeable drugs are not eligible for special authorization.
Some higher cost medications will be limited to 30 days’ supply to reduce the potential for drug wastage due to loss, damage, or a change of therapy. If you are travelling outside of your province of residence and need more than a 30-day supply of your prescription, you’ll need to use the Travel Supply of Prescription Drugs Request prior to visiting your pharmacy.
You can visit the Drug Inquiry Tool on My ASEBP to see if a drug you’ve been prescribed requires special authorization.
Annual Expiry Notification
Covered members with an approved drug special authorization will receive an expiry notification email (to the email address indicated in their My ASEBP account) or letter (if they don’t have an account), three months prior to the expiration. Please follow the steps outlined in the notification to avoid a lapse in coverage.
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. Within this program, you will need to show that you have completed an adequate trial of 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 may 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:
- Stomach hyperacidity
- High blood pressure
- Pain/inflammation management (non-narcotic)
- Migraines
All the medications identified as preferred alternatives are proven to be equally safe and effective to their brand or generic counterparts. 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:
- 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
- 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:
- The submission of the authorization is not a guarantee of approval, and
- 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.