Formulary Info Sheet

Most prescription drug plans are based on a formulary or list of eligible drugs that can be wide open or very restrictive. A wide- open formulary ensures that employees have access to almost all drugs they might need. A restricted formulary limits what drugs the plan will cover. NexgenRx   offers a variety of formularies to suit the plan sponsor's needs.

NxOTC Formulary 
This formulary is comprehensive and includes most of the drugs prescribed on a regular basis in all provinces and territories. Drugs and supplies generally fall into one of three categories:

  • Prescription by law at the federal or provincial level. None of these drugs can be purchased without a prescription from a licensed doctor, dentist or other recognized health professionals such as nurse practitioners and podiatrists who have authority to prescribe selected medications. These categories include, but are not limited to, drugs used to treat cardiovascular disease, depression and related mental health conditions, thyroid supplements, antibiotics, oral hypoglycemics for diabetes, oral contraceptives, hormone replacement, seizure disorders, multiple sclerosis, cancer, asthma, arthritic conditions, skin diseases and HIV. New drugs coming to market in Canada would generally fall into this category.
  • Over the Counter Drugs (OTC). This category includes the commonly prescribed pain medications like acetaminophen (Tylenol) and ibuprofen (Advil), cough and cold medications like dextromethorphan, guaphenesin, pseudoephedrine contained in numerous formulations from a variety of manufacturers, calcium supplements, gastrointestinal products like Maalox and Imodium, nicotine replacement patches, gum and inhalers and skin products. This class of drugs/supplies would only be considered eligible on a NxOTC formulary if a prescription (written or verbal) is issued for the plan member or eligible dependent, even though they do not legally require a prescription.
  • Life Sustaining OTCs. Drugs such as insulin conventionally have been considered eligible on most drug formularies even though they do not legally require a prescription. This class of products also includes diabetic test strips, disposable insulin needles and syringes, oral potassium supplements, Epi-Pen, nitroglycerin for immediate release, low dose aspirin (81mg or 325mg) for blood thinning, niacin for cholesterol lowering, vitamin B12 for certain types of anaemia as examples. This class of drugs/supplies will only be eligible on NxOTC if a prescription (written or verbal) is issued for the plan member or eligible dependent.

NxRX 
This formulary includes most drugs that are prescription requiring at the federal or provincial level. None of these drugs can be purchased without a prescription from a licensed doctor, dentist or other recognized health professionals such as nurse practitioners and podiatrists who have authority to prescribe selected medications. This category includes drugs used to treat cardiovascular disease, depression and related mental health conditions, thyroid supplements, antibiotics, seizure disorders, oral hypoglycemics for diabetes, oral contraceptives, hormone replacement, multiple sclerosis, cancer, asthma, arthritic conditions, skin diseases and HIV. New drugs coming to market in Canada would generally fall into this category. 
The formulary includes drugs used to treat infertility and smoking cessation (Zyban). These classes can be removed from the formulary for specific plan sponsors or be eligible for a lifetime maximum dollar value as part of the plan design. 
NxRX also includes the class of Life Sustaining OTC drugs (described under the NxOTC formulary above).

NxSSG 
This formulary is designed to be used with the NxRX formulary as part of a two level plan design. Drugs fall into three source categories:

  • Single Source. These drugs are usually marketed by a brand name manufacturer and have a patent not yet expired. Single source drugs are usually older drugs with no generic interchangeable product. 
  • Brand Name with interchangeable generics. Many generic manufacturers are willing to bring their version of the single source drug to the Canadian market when the patent expires, however, not all generic products get listed on all provincial/ territorial formularies. The generic versions that do get listed are considered to be interchangeable with the brand name drug. This means the pharmacist does not have to call the doctor to substitute the brand name with one of three or four generic products from manufacturers like Apotex, Novopharm, GenPharm, Pharmascience and Nu-Pharm.

    Some brand name manufacturers will lower their costs to meet the price of the generic companies in an effort to maintain their market share but this tends to be the exception. Many pharmacies will no longer stock the brand name after a generic is considered interchangeable, unless by specific request.
  • Generic Interchangeable Drugs. The generic manufacturers have to prove to Health Canada their products have the same active ingredient and will have a similar mode of action even though the "fillers" or non-active ingredients may differ from the original brand name drug. Each province decides which generic products to list as interchangeable. Quebec and some of the western provinces may include generic products from manufacturers that are not included in the ODB formulary. This means separate files have to be maintained for each province with the correct interchangeable generics being linked to the brand name. Depending on the plan, the only way the brand name may be eligible is if the prescribing physician has specifically indicated in his/her handwriting "No Substitution" should take place. There is a small percentage of the population that is allergic to a generic product but most people should be able to respond to the generic in the same way as to the brand name version.

This formulary provides coverage at two levels. The first pays for prescription-requiring single source drugs (SS) along with their generic interchangeable products (G) listed in plan NxRX at a higher level of co-insurance. All other prescription-requiring drugs from a brand name manufacturer are eligible on the second level of the plan but are paid at a lower level of co-insurance. Plan members who insist on the brand name, without having a proven allergic reaction to the generic products, will have to pay more for this request.

NxMC 
This is the NexgenRx   Canadian Managed Care Formulary, based on accepted Canadian clinical practice guidelines for physicians. It includes prescription-by-law drugs considered first or second line therapies used to treat the majority of disease states as well as the Life Sustaining OTC drugs integral to other NexgenRx formularies. Generics and line extensions of existing eligible drugs are automatically added. New single source drugs will be added after consideration of efficacy and pharmacoeconomic value. This plan design can control costs while adding new drugs that may improve the quality of life when combined with plan NxRX at a lower level of co-insurance. 
Classes of drugs eligible on the NxMC formulary include but are not limited to: Analagesics Anti-infectives Anticonvulsants Antidepressants Asthma Cardiac Cholesterol Lowering Dermatology Diabetes Gastro-intestinal Hypertension Hormone Replacement Oral Contraceptives Sedatives Thyroid.
This plan offers the plan sponsor the option of only paying the generic price of interchangeable drugs.

Standard Exclusions from NexgenRx™   Formularies

  • Drugs used in hospital emergency rooms and operating rooms
  • Cosmetic products used to prevent or treat sun damage or age related skin conditions (e.g. Renova,Rejuva) including topical sunscreens, skin bleaching agents (e.g. Eldoquin), cosmetic peels(e.g. glycolic acid) and any skin products which are advertised as a cosmetic enhancer. This would include the entire range of Neostrata and Neutrogena products.
  • Products used to remove hair (e.g. Vaniqa) or promote the growth of hair (e.g. minoxidil and Propecia)
  • Oral erectile dysfunction drugs (e.g. Viagra, Cialis, and Levitra)
  • Anti-Obesity drugs (e.g. Xenia, Meridia)
  • Contraceptive devices with no medication (e.g. copper IUDs, diaphragms, condoms)
  • Lozenges, dental products, most mouthwashes
    Aero chambers, spacer/extension devices for use with inhalers
  • Glucometers, home blood pressure monitors, peak flow meters, while useful in terms of wellness outcomes would be considered part of extended health benefits and not eligible on the drug benefit plan
  • All dressings unless containing an active drug (e.g. Fucidin)
  • Vitamins, minerals except vitamin B12 (cyanocobalamin), calcium or calcium plus vitamin D. Magnesium, copper, manganese, selenium, dolomite fall into the "alternative health” category and would not be eligible.
  • Homeopathic, herbal products (e.g. echinaea, St.John’s Wort, glucosamine, feverfew, CoQ10, evening primrose oil) fall into the “alternative health” category
  • Disinfectants, hand sanitizers, alcohol swabs and rubbing alcohol
  • Drugs which have not received an NOC in Canada but may be prescribed and supplied through a special access program on an individual basis
  • Nutritional supplements including infant formula, total parenteral nutritional products and oral products like Ensure
  • Blood products used to treat haemophilia or immune globulins for passive, temporary immunization
  • Medical gasses (e.g. oxygen)
  • Dialysis products
  • Supplies for insulin pumps (e.g. tubing, non-disposable syringes, and batteries)
  • X-Ray contrast media
  • Lactase products designed to be added to dairy products (e.g. Lactaid drops)
  • Dandruff shampoos promoted as "cosmetic" (e.g. Selsun Blue, Head and Shoulders)
  • Preventative vaccines (e.g. Dukoral, TwinRix)
  • Growth hormones
  • Ostomy supplies

Specific classes can be included in the plan design at the request of the plan sponsor.