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Health Benefits Card Coverage

Published Date: August 01, 2011
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06 Prescription/Non-Prescription Drugs and Nutritional Products

ISTHB Regulation, Section 73(2)(a) provides for drug coverage in accordance with approved drug lists.


INTENT

To provide coverage for essential prescription and non-prescription drugs and nutritional products to ensure health and well-being.

POLICY

Clients eligible for health benefits receive coverage for prescription drugs, non-prescription drugs and nutritional products listed on the Alberta Health Drug Benefit List (DBL) and the Community and Social Services Drug Benefit Supplement List (DBS). In all cases, a prescription written by a physician or valid prescriber is required.

Requests for drugs and nutritional products not listed on the DBL or DBS may only be authorized by the Health Benefits Exception Committee.

Interactive Drug Benefit List

The Interactive Drug Benefit List is an online, searchable database for Alberta Government-sponsored drug programs and includes all of the products on the DBL and the DBS.

Alberta Health Drug Benefit List (DBL)

The DBL includes:

  • Drugs covered by drug programs sponsored by Alberta Health
  • Interchangeable alternatives for many drugs with pricing information on the Least Cost Alternative (LCA)
  • Drugs with Restricted/Limited coverage and the criteria which must be met for coverage of these drugs,
  • Drugs only available by Special Authorization and the criteria which must be met for coverage of these drugs


Community and Social Services has adopted the DBL with the exclusion of fertility drugs, and other drugs when used for the treatment of infertility.

Community and Social Services pays the lower of the least cost alternative price or actual acquisition cost where an interchangeable product can be used to fill a prescription. Clients may choose a higher priced interchangeable alternative; however, the client must pay the additional cost.

Community and Social Services Drug Benefit Supplement (DBS)

The DBS includes nutritional supplements and non-prescription (over-the-counter) products such as:

  • Pre-natal vitamins
  • Specialized infant formulas
  • Children’s vitamins and cold medications
  • Nutritional products such as Boost and Ensure
  • Smoking cessation and nicotine replacement products
  • Interchangeable products, where appropriate, with pricing information on the Least Cost Alternatives


Many products on the DBS are restricted benefits, only available to individuals up to 17 years of age inclusive.

Role of Alberta Blue Cross (ABC)

ABC administers payments for prescription drugs, non-prescription drugs and nutritional products on behalf of Community and Social Services.

Administration includes prescription limits on Days Supply. Criteria developed in consultation with the Alberta College of Physicians and Surgeons, Pharmacists Association of Alberta, Alberta Medical Association and ABC limit the Days Supply that can be dispensed. Days Supply can vary from 14 days for antibiotics, to 30 days for antidepressants, central nervous system drugs and pain medications, to 100 days for chronic medications not included in the two previous categories. If the doctor prescribes in excess of the Days Supply limit, the patient may obtain a refill from the pharmacy.

ABC also monitors client drug usage to determine potential drug misuse.

Special Authorization by ABC

Special Authorization criteria have been established for some drugs on the Interactive Drug Benefit List where:

  • The drug is intended only for the treatment of specific diseases or medical conditions
  • Where standard drug therapy has failed, or has proven ineffective
  • Where the patient has been unable to tolerate standard drug therapy


Special Authorization criteria have also been established for some specialized infant formulas where:

  • The formula is intended for use by infants with specific medical conditions (e.g. cow’s milk protein allergies)
  • The infant has been unable to tolerate other infant formulas
  • The infant has nutritional requirements that cannot be met by other formulas

Note
Alimentum, Nutramigen and Neosure are regular benefits on the DBS. Neocate is available by Special Authorization.

 If a drug or infant formula is available by Special Authorization, the coverage criteria and Special Authorization request forms are available as links from the Interactive Drug Benefit List. The forms are also available through:

Alberta Blue Cross
Customer Service
Phone: Edmonton and area 780‑498‑8000
Toll-free from all other areas 1‑800‑661‑6995

It is the responsibility of the client’s physician or dentist to request Special Authorization from ABC. The physician or dentist forwards the Special Authorization request to:

Alberta Blue Cross
Clinical Drug Services and Evaluation
10009-108 Street NW
Edmonton, AB T5J 3C5
Fax: Edmonton and area 498‑8384
Toll-free from all other areas 1‑877‑828‑4106

Approval or denial of the Special Authorization request is sent by ABC in writing to the client and the physician.

Physicians and pharmacists are generally well informed regarding specific products and the need for Special Authorization. Special Authorization can be granted for periods up to 24 months, depending on the drug or nutritional product.

Coverage for select drugs may be provided through the step therapy Special Authorization process. Drugs available by step therapy are considered second or third line therapies. Prior to receiving coverage for a step therapy drug, the client must try a first line drug. These first line drugs are listed on the DBL under Special Authorization criteria. If a client has made a claim for first line drugs within the preceding 12 months, the claim for the step therapy drug will be approved by the Alberta Blue Cross automatic claims adjudication system.

Special Authorization for selected drugs may be renewed automatically. If the client has submitted a claim for the drug within the approval period, Special Authorization will be automatically renewed for an additional approval period. If the client does not submit a claim within the approval period, Special Authorization coverage will lapse.

It is the responsibility of the client and physician to re-apply for coverage prior to the expiration of the approval period unless the auto-renewal process applies.

Health Canada Approved Drugs

Health Canada is the therapeutic regulator for pharmaceutical products in Canada. If a drug has not been approved by Health Canada, it will not be approved by Alberta Health for the Drug Benefit List.

Appeal and Health Benefits Exception Committee

Decisions regarding drugs and nutritional products provided as a Community and Social Services health benefit are defined in Regulation as decisions of the Minister, and therefore, not subject to appeal to an appeal panel.

If the requested drug or nutritional product is not listed on the Interactive Drug Benefit List, is not available by Special Authorization, or if Special Authorization has been denied, the client may request that the Health Benefits Exception Committee (HBEC) approve coverage.

Note
The HBEC generally meets once a week. If the supervisor determines the client’s health may be at risk while waiting for an HBEC review, the supervisor should identify the request as urgent and fax 780‑422‑3646.

Extended Renewal for HBEC Approved Drugs and Nutritional Products

Alberta Blue Cross applies an extended renewal process to drugs and nutritional products that are appropriate for long term use and have been approved for a client by the HBEC. Clients are able to access the approved drugs and/or nutritional products for as long as their files remain active and their physicians continue to prescribe the products. The extended renewal process will not apply in cases where it has been more than 12 months since the item was dispensed to the client. A list of the drugs and nutritional products appropriate for extended renewal can be found here.

Payment Method

Recipients present their Health Benefits Card (HBC) to the pharmacist in order to have their prescriptions filled.

If the recipient is entitled to prescription drug services, but does not have a HBC, the worker issues an EMP 1976 Drug Authorization.

The EMP 1976 Drug Authorization is used when:

  • Clients require drugs prior to issuance of a Health Benefits Card.
  • A new dependant is added to the file during the benefit period.
  • A restricted client must obtain a prescription from a drug store other than the one they were restricted to at the beginning of the benefit period, if for example they moved or had to travel to another location in Alberta for medical treatment.
  • One-time issue clients require Emergency Prescription Drugs.

    Note
    Pharmacists should be reminded that the EMP 1976 Drug Authorization is not an approval for a specific drug, but rather an authorization for drug services in accordance with the drug benefit program guidelines.

If the requested drug is not on the Interactive Drug Benefit List, and not available by Special Authorization, then the applicant can request a review by the Health Benefits Exception Committee.

The HBC and EMP 1976 Drug Authorization are the only methods of payment for drugs, with the exception of allergy serum.

Allergy Serum Exception

In order for some allergy serum to be effective, it must be dispensed fresh or at a specific temperature. As a result, some serums are sent or dispensed directly from the manufacturer to the client. As both the EMP 1976 Drug Authorization and the HBC can only be used to pay a licensed pharmacist, an EMP 0018 Purchase Authorization and Invoice is used in these circumstances only.

Service Description for Allergy Serum

The appropriate Goods Code, Need Code and Description for the allergy serum must be included on the EMP 0018 Purchase Authorization and Invoice. The period in the description must be the same as the Period of Assistance on the EMP 0018 Purchase Authorization and Invoice, and must cover the dates of service on the vendor’s claim form.

Ongoing Need for Drugs and Diabetic Supplies

Individuals and families with sufficient ongoing income to cover their basic needs, but not enough income to cover the high ongoing cost of prescription drugs and diabetic supplies, may be eligible for coverage under the High Drug Needs sub-type of the Alberta Adult Health Benefit program.