Important information about your drug plan

#275
PDF version

We recently learned that when filling a prescription and using their drug card, some plan members are being charged more than they expected, based on the provisions of their drug plan. As a result, you may receive questions from those plan members. Below we have outlined the circumstances that may have led to these unexpected charges. The amount charged by a pharmacy for filling a prescription has two components:

  • The drug ingredient cost
  • The pharmacy’s dispensing fee

Our Pharmacy Benefit Manager, TELUS Health Solutions (TELUS), establishes contracts with pharmacies that set specific limits on how much the pharmacy will be reimbursed for drug ingredient costs and dispensing fees.

  • If a pharmacy submits a drug claim where the ingredient cost of the prescription is higher than the set limit, the payment from TELUS to the pharmacy will be cut back to the set limit. Under the terms of their agreement with TELUS, the pharmacy is not allowed to pass on those extra costs for the drug ingredient to plan members.
  • If a pharmacy’s dispensing fee is higher than the set limit, the pharmacy may pass on those extra costs to plan members.  However, pharmacies in Atlantic Canada are not allowed to charge those extra dispensing fee costs to plan members.

If a plan member is being charged more than they expected, we encourage them to talk to their pharmacist.  If the extra charges are due to the pharmacy’s ingredient costs (or, in Atlantic Canada, their dispensing fees) priced over the limit set by TELUS, then the pharmacy will be able to make the appropriate adjustment.  If the extra charges are not adjusted, we encourage the plan member to contact our Customer Care Centre so that we can investigate further.

In Quebec, unlike other provinces, pharmacies submit a combined amount where the drug ingredient cost and dispensing fee are not separated. The TELUS agreement with the Quebec pharmacy association is that pricing must be based on reasonable and customary charges.

It’s important that plan members realize:

  • these set limits only apply if a member uses their drug card.
  • all pharmacies do not charge the same ingredient cost and dispensing fee.
  • If members with a pay-direct drug card pay for the prescription and then submit the claim to Sun Life Financial for reimbursement, pharmacists are not bound by these limits. The amount reimbursed by the drug plan will be based on the TELUS limits so the member will be out-of-pocket any amounts over the set limits.

Please share the enclosed communication with your plan members.

Questions?

Please contact your Sun Life Financial group representative.