Some of the most common questions heard in the WTA office are about drug plan coverage. Why was my claim denied? What drugs are covered and what aren’t? What does Part Three mean? Why didn’t the Bombers just go for it on third and 4? While only the coaches can answer the football questions that has nothing to do with drug plan coverage, this article can hopefully answer the other three.
The Manitoba Formulary is a list of drugs covered by the your Manulife drug plan. It includes all drugs covered by Manitoba Pharmacare, including most common drugs. These common drugs are referred to as Part One drugs and are typically automatically approved for use by Manulife. Certain more expensive drugs are considered Part two or Part Three, these require additional paperwork before Manulife will pay for them.
This drug formulary is a listing of covered medications which includes thousands of prescription drugs chosen for their quality and cost efficiency. The listing is developed by a committee of physicians and pharmacists and is reviewed regularly, adding new drugs as they become available, or replacing or deleting drugs when a better alternative is available. This formulary is also the basis for the Manitoba Pharmacare program.
The Manitoba provincial drug formulary also includes a list of interchangeable drugs, which include different brands of the same drug in different strengths and dosages that are also available in a generic form with the same therapeutic effectiveness.
Your drug plan through Manulife integrates with the Manitoba Pharmacare program. Your pharmacist submits your drug claims to both Manulife and Manitoba Health. When your Pharmacare deductible is met, responsibility for claims payment automatically shifts from Manulife to Manitoba Health. In order for this integration to occur, you will need to apply for your Pharmacare deductible.
Part Two and Part Three Drug Coverage
If your claim is initially denied, it may be because your drug is considered a Part Two or Part Three drug. For a drug to be eligible as a Part Two drug, it needs to meet criteria set out by Manitoba Health as to the condition for which it’s being prescribed. The same drug could be eligible as a Part Two drug for one condition and not for another. Your physician needs to indicate the condition for which you’ve been prescribed the drug on your prescription. Eligibility is determined when the pharmacist submits the information to Manitoba Health on your behalf. For Part Three drugs, you and your physician need to apply to have this drug approved specifically for you, both to Manitoba Health, and to Manulife. Manulife will also require a copy of your Manitoba Health approval letter. Manulife’s Prior Authorization forms for these drugs are available on the plan member website under the claim forms tab when you uncheck the critical illness box.
How can I work with my health care practitioners so that the drugs they prescribe are covered under my plan?
Tell your healthcare practitioner that your benefits plan includes coverage for drugs listed on the Manitoba provincial drug formulary. He or she can then use this information to make choices about the drugs they prescribe to treat you or the members of your family. Sometimes, you or a member of your family will require a drug that is not covered under the formulary. If you meet certain criteria, your physician can apply to Pharmacare to have this drug covered as an exception for you. Pharmacare reviews the application and decides whether to grant Exceptional Drug Status for you or your family member. You would receive a letter stating whether or not the drug has been approved for inclusion, and for how long. You can forward a copy of this letter to Manulife in order to have prescriptions for this drug paid under the terms of your plan up to your Pharmacare deductible. Please note that Pharmacare does not allow retroactive claims payment after approval, so it’s important to get approved for coverage prior to purchasing the drug.
The Choice is Yours
Remember, if you decide that you would prefer a more expensive drug rather than the less expensive equivalent you have been approved for, you can choose to pay the difference.
Submitted by Matthew Jones, with additions from AON Hewitt