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What is mandatory generic substitution?

December 3, 2018

To help manage the costs associated with prescription drugs, the OSSTF Benefits Plan includes mandatory generic substitution.

With a mandatory generic drug plan, any prescribed drug cost cannot exceed the price of the lower cost alternative drug, which is typically a “generic” drug.

  • If the drug you are prescribed is a “brand-name drug,” and there is no generic or interchangeable drug, your plan will reimburse you the cost* of the brand-name drug.
  • If there is a generic drug and you choose to buy the brand-name drug, your plan will reimburse you the cost* of the generic drug only.
  • In some instances, you may experience an adverse reaction to the generic drug, or it is therapeutically ineffective. When this happens, medical evidence can be submitted to support why the brand-name drug is being prescribed. To get approved for a brand-name drug, you need to complete the Request for Approval of Brand-Name Drug form (www.otip.com/forms), have it signed by your doctor and return it to the address on the form. If approved, you will be paid back the cost* of the brand-name drug.

*Reasonable and customary will be applied to the eligible amount

Here’s an example1 of how mandatory generic substitution works:

Brand-name Generic
Drug Name: Crestor Apo-Rosuvastatin
DIN: 002247162 02337983
Strength: 10 mg 10 mg
Quantity: 90 tablets 90 tablets
Cost of the drug: $161.82 $24.60
Your plan covers: $24.60 $24.60
You Pay2: $137.22 $0.00
1Examples and pricing are based on the Ontario
market and provided by My drug plan tool. Prices
are estimates only, regional differences may vary,
and include some drug mark-ups. If you are
eligible for a dispensing fee, it will be included in
the drug cost shown in My drug plan.2As per your benefits plan, you are reimbursed for
the lowest cost alternative (generic drug).

When filling a prescription – speak up!

In many provinces, pharmacists will automatically dispense the generic alternative as part of their standard practice unless the prescribing doctor has indicated that “no substitutions” should be made. If your doctor has indicated “no substitution,” you can ask your pharmacist to dispense the generic drug – or you can accept the brand-name drug, and pay the price difference between the brand-name and the generic drugs.

If you share in either the cost of your plan or the cost of your prescription, switching to generics may help you and your plan save some money!

Use My drug plan to look for generic drug options

My drug plan is a user-friendly, drug lookup tool (found in My Claims quick links). It can help you to manage your drug costs especially because you have a mandatory generic drug plan. You can find out if a generic drug is available or if prior authorization is needed. A drug library is also right at your fingertips.

IMPORTANT NOTES:

  • Drug costs seen in My drug plan are estimates only.
  • With a mandatory generic drug plan, any prescribed drug cost cannot exceed the price of the lower cost
    alternative drug, which is typically a “generic” drug.

    • If the drug you are prescribed is a “brand-name drug,” and there is no generic or interchangeable drug, your plan will reimburse* you the cost of the brand-name drug.
    • If there is a generic drug and you choose to buy the brand-name drug, your plan will reimburse* you the cost of the generic drug.

In some instances, you may experience an adverse reaction to the generic drug, or it is therapeutically ineffective. When this happens, medical evidence can be submitted to support why the brand-name drug is being prescribed. To get approved for a brand-name drug, you need to complete the Request for Approval of Brand-Name Drug form, have it signed by your doctor and return it to the address on the form. If approved, you will be paid back* the cost of the brand-name drug.

*Before you get any money back, reasonable and customary limitations, coinsurance\reimbursement, deductibles and/or maximums apply as per the terms and conditions in each plan (refer to your benefits booklet).


The information in this document is provided by OSSTF Benefits for general information only. OSSTF Benefits endeavours to have all information current and accurate. We make no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, or suitability of the information included. All information is subject to change without notice.


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