Formulary Info Sheet

Most prescription drug plans are based on a formulary or list of eligible drugs that can be open or more restrictive. An open formulary ensures that eligible plan members have access to the majority of drugs approved by Health Canada. A restricted formulary limits what drugs the plan will cover. NexgenRx   offers a variety of formularies to suit the plan sponsor's needs.

NGOTC Formulary

This formulary is comprehensive and includes most of the drugs with a valid DIN 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, asthma, arthritic conditions and skin diseases.
  • 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, guaifenesin, pseudoephedrine contained in numerous formulations from a variety of manufacturers, gastrointestinal products like loperamide (Imodium), and ranitidine (Zantac) and non -cosmetic skin products. This class of drugs/supplies would only be considered eligible on a NGOTC 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, , pre-loaded adrenaline pens, nitroglycerin for immediate release,  aspirin (81mg or 325mg) for blood thinning, , and injectable vitamin B12 for certain types of anemia as examples. This class of drugs/supplies will only be eligible on NGOTC if a prescription (written or verbal) is issued for the plan member or eligible dependent.

NGRX

This formulary includes the majority of 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, and skin diseases. Drugs that are administered by the intravenous route by a health care professional may only be eligible as benefits for individuals who have applied for a cardholder exception.

NGRX also includes the class of Life Sustaining OTC drugs (described under the NGOTC formulary above).

Generic Interchangeable Drugs. Generic manufacturers have to prove to Health Canada that their products have the same active ingredient (s) 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 and territory with the correct interchangeable generics being linked to the brand name. Depending on the plan design, the only way the brand name may be eligible is if the prescriber has specifically indicated in his/her handwriting "No Substitution" should take place. There is a small percentage of the population that may have documented adverse reaction[s] 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.

NGMC

This is the NexgenRx   Canadian Managed Care Formulary, based on accepted Canadian clinical practice guidelines for physicians and other authorized prescribers. It includes prescription-by-law drugs considered first or second line therapies used to treat the majority of disease states. 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 NGRX at a lower level of co-insurance.

Classes of drugs eligible on the NGMC formulary include but are not limited to: Analgesics, Anti-infectives, Anticonvulsants, Antidepressants, Asthma, Cardiac, Cholesterol Lowering, Dermatology, Diabetes, Gastro-intestinal Hypertension, Hormone Replacement, Oral Contraceptives, Sedatives and Thyroid.

This formulary offers the plan sponsor the option of only paying the generic price of interchangeable drugs.

Standard Exclusions from NexgenRx™  Formularies include :

  • Drugs used in hospital emergency rooms , operating rooms and drugs administered by intravenous injection
  • Cosmetic products used to prevent or treat sun damage or age related skin conditions including topical sunscreens, skin bleaching agents, 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 finasteride )
  • Erectile dysfunction drugs (e.g.Muse, Viagra, Cialis, and Levitra)
  • Anti-Obesity drugs (e.g. Xenical, Saxenda)     
  • Contraceptive devices with no medication (e.g. copper IUDs, diaphragms, condoms)
  • Lozenges, dental products, most mouthwashes.
  • Glucometers, home blood pressure monitors, peak-flow meters, aero chambers, spacer/extension devices for use with inhalers. While useful in terms of wellness outcomes these devices would be considered part of extended health benefits
  • All dressings unless containing an active drug Vitamins  except vitamin B12 (cyanocobalamin ) injections and  minerals such as  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. echinacea, 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, Boost and Glucerna
  • Blood products used to treat hemophilia 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, Gardasil 9,)
  • Growth hormones
  • Ostomy supplies
  • Allergy vaccines

Specific classes such as infertility drugs and smoking cessation can be included in the plan design at the request of the plan sponsor.

Generic Interchangeability: Each province and territory has its own unique formulary with generic equivalents where applicable. If a generic product is considered interchangeable in a province's formulary then the plan sponsor may request that only the price of the lowest priced interchangeable generic product may be paid. Some plan sponsors may allow  'Doctor No Substitution' if this is indicated in the prescriber's handwriting ,then the brand name will be paid. If, however, the patient insists on the brand name without this designation from the prescriber, then the patient is responsible for paying the difference between the brand name price and the adjudicated price. Mandatory generic substitution applies similar principles as generic substitution, which is when the plan will pay for the generic equivalent of a drug (when it is available), unless a prescriber insists on a name-brand drug. The key difference is that even if the member submits a prescription with "no substitution" indicated at the pharmacy, the plan will reimburse only up to the cost of the generic drug even if a brand name drug is dispensed.