BRAND NAME DRUGS AND GENERIC SUBSTITUTION UNDER ASEBP

When a physician prescribes a brand name medication and the pharmacy dispenses a generic version, questions occasionally arise. Alberta School Employee Benefit Plan (ASEBP) follows the standard industry approach to drug coverage that explains why this occurs and outlines the available options.

Basic Eligibility for Prescription Drug Coverage

ASEBP provides comprehensive prescription drug coverage. To be eligible, a drug must be prescribed by a licensed Canadian healthcare provider, dispensed by a licensed Canadian pharmacy, purchased in Canada while the member or dependent is covered and used for its intended purpose as defined by Health Canada.

Brand Name and Generic Drugs: What Is the Difference?

Brand name drugs are developed and patented by pharmaceutical manufacturers and sold under a trade name. Once the patent expires, other manufacturers may produce generic versions.

Generic drugs must contain the same active ingredient, have the same dosage, strength, quality and performance, use the same delivery method (for example, oral or intravenous) and have the same intended use as the brand name product. Health Canada requires generics to demonstrate bioequivalence, which means that they should function in the body in the same way as the brand name product. While nonmedicinal ingredients (such as fillers or dyes) may differ, the therapeutic effect must be the same.

 Why the Pharmacy Dispenses the Generic Drug

For many medications, ASEBP reimburses based on the therapeutically equivalent alternative that is lowest in cost. If a generic equivalent is available, reimbursement is based on its cost, and pharmacies will typically dispense the generic, unless the prescriber indicates a medical reason for not making the substitution.

If a member chooses the higher-cost brand name product when a lower-cost generic equivalent exists, the plan reimburses only up to the cost of the generic, and the member pays the difference. Eligible out-of-pocket costs may be claimed through a spending account, if available.

When a Brand Name Drug May Be Covered

Members may request the brand name product; however, reimbursement at the brand price requires medical justification.

An appeal may be submitted when there is a clinical rationale that the generic or lowest-cost product is not appropriate. This may include situations where the generic has been ineffective, has caused an adverse reaction or allergy to one of its components, or where another documented medical reason prevents its use. Preference alone is unlikely to be a reason for approval. Supporting medical evidence is required.

Special Authorization

Some medications require special authorization before coverage is approved. This process is separate from generic substitution and generally applies to higher-cost or clinically complex drugs.

If required, the prescribing provider must complete the appropriate request form, either directly or with assistance from the pharmacist. Both the member and the provider are notified once a decision is made. Decision letters are posted in the Documents section of the member’s My ASEBP account, and users receive an e-mail notification when a new letter is available.

If approved, reimbursement follows the member’s plan provisions. Some medications require renewal. Over-the-counter products and specific brands of interchangeable drugs are ineligible for special authorization.

Certain higher-cost medications may be limited to a 30-day supply to reduce waste from loss, damage or a change in therapy. Members travelling outside their province of residence who require more than a 30-day supply must submit a Travel Supply of Prescription Drugs Request before visiting the pharmacy.

Members can confirm whether a drug requires special authorization by using the Drug Inquiry Tool in My ASEBP.

WORTH SHARING

If your doctor prescribes a brand name drug but the pharmacy provides a generic one, this is typically because ASEBP reimburses based on the therapeutically equivalent option that is of lowest cost. Generic drugs contain the same active ingredient, have the same strength and dosage p 3 and are intended for the same use as the brand name version and are approved by Health Canada as bioequivalent. You may choose the brand name product; however, if a lower-cost equivalent exists, you will pay the difference, unless there is a medically supported reason the generic is not appropriate. In those cases, your healthcare provider can submit documentation requesting coverage of the brand name drug.

Some medications require special authorization before coverage is approved. You can check the requirements using the Drug Inquiry Tool in your My ASEBP account. If you have questions about a substitution, first speak with your pharmacist. For additional assistance with ASEBP matters, contact Teacher Employment Membership Support (TEMS) at 1-800-232-7208.

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