Drug Benefit

Mandatory conditions

To be eligible for reimbursement under the Plan, expenses for drugs must first meet the following conditions:

  • The expenses must be the reasonable and customary charges.
  • The drug must be prescribed by a physician, dentist or other qualified health professional if the applicable provincial/territorial legislation permits them to prescribe the drugs.
  • The drug must be dispensed by a pharmacist or physician.

While mandatory, these conditions are not sufficient for a drug to be covered by the Plan. Eligible expenses for drugs and related devices are identified below, and specific drugs that are not eligible for reimbursement are defined in the exclusions section.

 

Eligible expenses

Eligible expenses
Aerochambers

Aerochambers with masks for the delivery of asthma medication, regardless of the age of the patient.

Asthma drug delivery devices

Drug delivery devices to deliver asthma medication, which are integral to the product, and approved by the Administrator.

Baby formula Specialised formulas for infants with a confirmed intolerance to both bovine and soy protein. The attending physician must confirm this intolerance in writing.
Compounded prescriptions

Compounded prescriptions, regardless of their active ingredients.

Erectile dysfunction drugs

Erectile dysfunction drugs, limited to a maximum eligible expense of $500 annually.

Injectable drugs

Injectable drugs, including allergy serums administered by injection.

Life-sustaining drugs

Life-sustaining drugs that may not legally require a prescription and are identified in Schedule VII of the Plan Document.

Prescription drugs

Drugs that legally require a prescription and are identified in the Monographs section of the current Compendium of Pharmaceuticals and Specialities as a narcotic, controlled drug, or requiring a prescription, except for those specified in the General Exclusions and Limitations.

Replacement nutrients

Replacement therapeutic nutrients prescribed by an accredited medical specialist for the treatment of an injury or disease excluding allergies or aesthetic ailments, provided that there is no other nutritional alternative to the participant.

Smoking cessation aids

Smoking cessation aids (prescribed by a physician and dispensed by a pharmacist), to a lifetime maximum of $1,000 per participant.

Vitamins and minerals

Vitamins and minerals which are prescribed for the treatment of a chronic disease, when in accordance with customary practice of medicine, the use of such products are proven to have therapeutic value and no other alternatives exist.

 

Exclusions

No benefit is payable for:

  • Expenses identified in the General Exclusions and Limitations of the Plan
  • Experimental drugs
  • Items or products considered to be household remedies
  • Non-oral contraceptives
  • Vitamins, minerals, and protein supplements, unless they qualify under Eligible expenses
  • Therapeutic nutrients, unless they qualify under Eligible expenses
  • Diets and dietary supplements, infant foods, and sugar or salt substitutes, unless these qualify under Eligible Expenses
  • Lozenges, mouthwashes, non-medicated shampoos, contact lens care products, and skin cleansers, protectives or emollients
  • Drugs used for cosmetic purposes
  • Drugs used for conditions not recommended by the drug manufacturer (off-label indications)
  • Expenses payable under a provincial/territorial drug plan, regardless of whether the participant is covered by that plan.