Your AOMBT plan covers prescription drugs and medicines at 80%, with a deductible equal to the dispensing fee, until you’ve paid $1,200 out-of-pocket per year, at which point prescriptions are covered at 100%.
Medications are evaluated on the basis of safety, efficacy, and cost. Some very expensive drugs and those that have a risk of inappropriate use must have prior authorization to be eligible for reimbursement. For these drugs to be covered, their use must comply with clinical criteria and usage criteria recognized by medical and governmental authorities as well as customary and reasonable standards of practice generally accepted in the health care sector.
Sometimes doctors prescribe outside of the recognized usage criteria, for an illness or disease other than the reasons for use authorized by Health Canada and indicated on the product label. This is referred to as “off-label” prescribing.
As an example, some medications for diabetes have recently become popular to assist with weight management. In particular, Ozempic® has been making headlines for its effects – although this use is not compliant with Health Canada's approved indication.
Members with a history of type 2 diabetes continue to be eligible to claim Ozempic® through the plan, but if it’s prescribed for other reasons, claims will be denied, effective July 16, 2023.
Wondering if you can claim this or other medications? Log in to the Beneva app or Client Centre and click the “Price & coverage finder” button. You can search by drug name or identification number to see if you’re covered, and the average cost per prescription.
If you receive the “Drug not covered” warning, fill out a prior authorization form with your prescribing physician, and submit it directly to Beneva.
Read more about off-label prescriptions. (Canadian Agency for Drugs and Technologies in Health)