Reasonable and customary charges for covered prescription drugs, as long as the medication is medically necessary for the treatment of disease or injury and approved by Sun Life.
brand name prescription drug cost only if a generic drug equivalent does not exist.
of lowest alternative generic prescription drug cost if one is approved on the market, except if your physician completes a medical exception form for consideration if the brand name drug is medically necessary; the exception request will be reviewed by Sun Life and a decision will be communicated in writing to pay 95% of the brand name cost.
Expenses with a maximum reimbursable amount will be paid at 100%.
Per Script Fee
The plan will deduct a per script fee of $4.00 for each Drug Identification Number (DIN) claimed on an individual receipt if expense not purchased at a Preferred Pharmacy.
You pay the remaining cost.
Enhanced Prior Authorization Program
The Enhanced Prior Authorization Program ensures that members receive the most appropriate and cost-efficient drug therapy while reducing claims costs. At the same time, it minimizes the concerns of patients by using only credible and accepted clinical criteria to establish the authorization levels. Should a plan member choose not to submit a request or if the request does not meet the pre-determined criteria, the claim will be rejected.
To determine if a prescription drug is included in this program click on the following link (you will need to enter the contract number: 25298 once the page loads) or contact Sun Life Financial directly at 1-800-361-6212.
Prior Authorization is required for Speciality and Weight Loss drugs. For further information please see the “Eligible Expenses