Mandatory generic substitution was implemented to the PSHCP’s Drug Benefit as part of the plan design changes that came into effect on July 1, 2023. These changes included industry-standard cost-containment measures to ensure that the Plan remains fair, competitive, and sustainable.
Since July 1, 2023, prescription drugs under the PSHCP are subject to mandatory generic substitution. This means that the PSHCP provides coverage for eligible prescription drugs at 80% of the lowest-cost generic drug when a generic is available. Generic drugs are approved by Health Canada and are pharmaceutically equivalent to the brand name drug, as they contain identical medicinal ingredients.
If a prescription for a brand name drug is presented to the pharmacist and a generic version is available, the PSHCP member and their eligible dependants will have three options:
- Purchase the eligible generic drug, which the PSHCP will cover at 80%.
- Purchase the brand name drug, understanding that they will have a higher out-of-pocket amount (this is known as the co-pay amount), as the PSHCP will reimburse 80% of the cost of the generic version.
- If there is a medical reason that a generic brand cannot be taken, the participant should discuss the issue with a medical professional and request that they complete the Request for Brand Name Drug Coverage form. Any fees that a physician may charge for providing this information will not be reimbursed under the PSHCP.
The member should then submit the completed form to Canada Life at the mailing address, email address, or fax number located at the bottom of the form, and allow 7 to 10 business days for the review of the medical information provided. A letter will then be mailed to the member outlining the decision.
Prior to July 1, 2023, the PSHCP covered brand name drugs if the physician indicated “No substitutions” on the prescription. This process is no longer in place. However, under PSHCP’s legacy coverage, existing prescriptions where the brand name drug was covered under the PSHCP prior to July 1, 2023, will continue to be covered until December 31, 2023.
As of January 1, 2024, the legacy period will be terminated, and all members and their eligible dependant(s) will have their prescriptions subject to mandatory generic substitution.