Enhancing integration with provincial drug programs

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In January 2011 we will enhance our current drug claims management process to ensure that plan members access additional coverage opportunities available under provincial drug programs. 

The integration process will apply to all drug plans - plans with drugs cards and reimbursement plans. Our expanded program continues the evolution of our drug benefits and builds on existing integration with provincial drug programs.

Why are we enhancing your drug benefit program?

We currently have processes and controls in place to integrate with basic provincial drug plans. However, most provinces have programs that cover drugs beyond their basic provincial drug formularies.  For example, some provinces have disease-specific programs for multiple sclerosis or cystic fibrosis.  The programs vary by province and patients must meet medical criteria to qualify. The onus is on the patient and/ortheir physician to apply to the program. 

Based on a pilot project we conducted last year in British Columbia, we confirmed that many plan members are accessing these drug programs. Our enhanced claims management process will ensure that, where appropriate, eligible plan members have applied to the available government programs for coverage.

Directing drug claims to these programs will help manage the increases in the overall drug claims experience. It will also enable plan members and their dependants to receive as much coverage as possible.

What this means for plan members

When plan members request reimbursement for one of the identified drugs, the claim will be paid, according to plan provisions. However, we will also send the member a letter, advising that they may be eligible for coverage under a provincial drug program and require that they apply to the program

The letter will include information on how to apply and will ask that they notify Sun Life whether they have been approved or declined within 10 weeks of the date of the letter. Claims will continue to be paid during this period or until the member confirms the province’s response. 

If Sun Life does not receive a response from the member within the 10-week period, future claims for this drug will be declined.

  • For plans with a drug card, the pharmacy will receive the following message: “This medication is not eligible under your contract”.
  • For reimbursement plans, the claims statement will advise “This drug may be eligible for coverage under the provincial health insurance program. Please contact your doctor, pharmacist or provincial health insurance plan for more information.”

A copy of the plan member letter and the provincial drug coverage response form is enclosed for your information. 

How coverage will be integrated

  • If the province provides full coverage, the claimant will not be eligible for reimbursement through their group benefits plan.
  • If the province provides partial coverage, Sun Life will pay the remaining portion of the drug cost, according to the terms of the group benefits plan.
  • If the province does not provide any coverage, Sun Life will continue to cover the drug according to the terms of the group benefits plan.

Ongoing communication with plan members

For many of these provincial programs coverage is approved for a limited period of time, (e.g. 12 months) and the claimant must reapply and qualify for coverage to continue. We will periodically ask claimants to confirm that they are still eligible under the government program.

How this affects plan members

The process described above will apply to all claims for the identified drugs received on or after January 1, 2011 (both new and existing plan members).  

Note: This process will apply to all provinces (in January) except Quebec, New Brunswick, Nova Scotia, and Newfoundland.

  • In Quebec, because those with private plans do not have coverage through the provincial (RAMQ) plan, there is no opportunity to integrate;
  • In New Brunswick, Nova Scotia and Newfoundland integration will begin during the next phase of our provincial integration program.  We will communicate our processes for these Atlantic provinces in 2011.

As we transition to the next phase of our provincial integration program, we will amend our contract wording and will continue to monitorgovernment programs to identify additional opportunities for integration. Updates will be provided as we further expand the program.  

We are committed to innovative technology and effective claims management

Sun Life offers you and your plan members’ leading edge technology that can significantly enhance your claims processing experience. 

With the implementation of Sun Life’s FastForward claims and Fraud management technologies earlier this year, the processing of paper-based claims has been transformed. These technology enhancements include sophisticated scanning equipment, data liftsoftware, workflow and reporting capabilities. With ‘paper-claims’ in electronic format we are able to process targeted drug claims more efficiently to the benefit of the next phase of our enhanced integration with provincial drug programs.

Questions?

Please contact your Client Service Administrator at 1-877-786-7227.