DRUG BENEFITS 101

• Acute care drugs are used to treat one time or short term therapy conditions.
• Maintenance medications are used to treat chronic or long-term conditions.
• Speak to your pharmacist and/or physician about the quantity of drugs prescribed. He or she can recommend a larger supply of those drugs falling into the maintenance drug category, after the initial days supply is satisfied.
• Obtaining a larger supply of maintenance drugs can decrease the costs of dispensing and save you extra visits to the pharmacy.

Drugs used to fight infections caused by bacteria. They are not effective in working against viruses. Bacteria may change over time and become resistant – taking antibiotics unnecessarily, too often, or not finishing you prescribed dosage can lead to more resistant bacteria. Always complete your full prescription and do not save part of it to use another time. Follow the prescribed instructions – if they are not clear or you are unsure, ask your doctor or pharmacist to further explain. Never use antibiotics that were prescribed for someone else.

• Generic drugs contain the same active medicinal ingredients as the corresponding brand name, and are therefore considered therapeutic equivalents. However, substances combining the active ingredients may be different.
• In Canada, generic drugs are strictly regulated and must meet certain clinical standards in order for the drug to be substituted by the pharmacist.
• For the most part, generic products cost less and can reduce the costs of your health plan. Ask your health care professional to prescribe the generic drug whenever possible.

You pay a portion of the cost of your prescriptions by either paying the same amount each time (e.g. $5) or paying a percentage of the total cost (e.g. 20%). If you are paying a percentage, then you are encouraged to shop around for the best available dispensing fees and ingredient costs.

You pay a fixed amount each year before your coverage starts (e.g. first $100 of prescription costs).

Some drug plans cap (or limit) the amount that you will be reimbursed for the dispensing fee. In that case, a fixed amount is paid toward the professional dispensing fee charged on every prescription. As the plan member, you would be required to pay any difference between the capped fee and the dispensing fee.

The total cost of a drug to you or your drug plan is made up of a number of components

• Pharmacy dispensing fee (see above)
• Ingredient/manufacturer cost – the sale price charged by the manufacturer for the drug
• Wholesale mark-up – the amount added on to the manufacturer’s sale price by the wholesaler
• Pharmacy mark-up – the amount added on to the manufacturer and/or wholesaler price by the pharmacy

Drug pricing varies by pharmacy, region and province, and can sometimes vary depending on whether you pay the pharmacy out of your own pocket, or use your GSC ID card so that you only pay the portion not covered by your benefit plan. It’s okay to shop around for the best drug pricing.

A DIN (Drug Identification Number) is assigned to a drug product by Health Canada before it reaches the market. The eight digit number notifies the user that the product has been approved for use and can legally be manufactured and sold in Canada.

Medication compliance refers to both persistence (how long you take a medication) and adherence (to what degree you follow the prescribed directions for the medication). Put another way, medication non-compliance is when you don’t take the right drugs—at the right time—for the right length of time. Compliance is extremely important for effective disease management and avoiding risks of other health complications. Speak to your physician or pharmacist if you think you are having trouble complying with a prescription.

Occurs when you fill a prescription at the pharmacy, as long as you have a pay-direct drug plan. It’s a real-time system review of the current prescription and your historical claims profile, done while you are waiting for your prescription to be filled. Within five seconds, and before the drug is dispensed, we are able to notify the pharmacy of any drug-to-drug interactions, pharmacy hopping, double doctoring, duplicate therapies or duplicate ingredients, or prescriptions being filled too soon or too late. If a potential health hazard is identified, we will send a warning to the pharmacist, who in turn evaluates the response. He/she may contact your physician or provide advice. A DUR ensures drug therapy compliance, as it helps to ensure that medication is taken as prescribed. It improves health awareness by promoting consumer education and it increases your health safety and may reduce the overall cost of benefits.

A list of drugs that are covered as benefits, either through your provincial health plan, your group plan or your individual health plan. Each drug plan determines its own list of covered drugs.

A new prescription is dispensed in a smaller amount to start (e.g. 30 days). This helps to prevent wastage of costly medications in the event that you suffer from drug intolerance or want to change your prescription before you’ve finished taking all of the pills originally prescribed.

Often called “complementary” or “alternative” medicines, natural health products (NHPs) are substances that are used to restore or maintain good health. Natural substances include: vitamins and minerals, herbal remedies, homeopathic medicines, traditional medicines, probiotics, and other products such as amino acids and essential fatty acids. Some natural health products were once identified by Health Canada with DINs but have since been reclassified as NHPs. Because they no longer have a DIN, they are not eligible for coverage on GSC drug plans unless stated otherwise in your benefit booklet.

The prescriber must be a physician or another licensed health care practitioner with the authority to prescribe within the scope of their practice in their province.

These are drugs that have a drug identification number (DIN), that by law, require a prescription for sale and are provided to the public by a pharmacist after the diagnosis and professional intervention of a health care practitioner. Examples: Penicillin, Imitrex, Ventolin, and Tylenol #3.

Some drug plans only cover certain medications for specific medical conditions. In these cases, prior approval is required. Your doctor may need to fill out a special authorization form for these types of medications before your plan will pay for the drug.

A professional (or dispensing) fee is the amount a pharmacy charges for providing professional services such as patient counseling, monitoring drug therapy, providing drug information to physicians and dispensing drug products. It also covers stocking of medication and maintaining patient medication records. Dispensing fees can differ from pharmacy to pharmacy – making a big difference in the total cost of the prescription. If you are not happy with the dispensing fee that your pharmacy charges, it’s okay to shop around to find a better price. (In Ontario, pharmacies are required to post their average dispensing fee so that it is visible to all customers.)

One of the key differences between traditional medications and biologics is in how each is manufactured. Traditional drugs are chemically synthesized in a process that is relatively easily replicated—think of these as recipe-based products. Biologics are derived from living cells, tissue or micro-organisms using much more complex, highly controlled manufacturing processes that are unique to each drug. They are more expensive to research, manufacture, store and deliver than pharmaceuticals—and, as a result, they can cost much more. According to GSC’s administrative guidelines (these are the rules that guide how we pay claims), all plans default to covering the most therapeutically and cost-effective agent within a class first, allowing you to move on to other agents in the class only when you experience an undesired response to the first drug.