REMINDER: Amendment to your Extended Health Care Benefit Contract

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As per our original communications released July 28 this update amends the exclusion to services or supplies payable or available under a government sponsored program. The revised contract wording will allow us to now expand integration with these kinds of programs in Atlantic Canada.

Our goal is to ensure that plan members access coverage opportunities available under government-sponsored drug programs and maintain sustainable benefit plans for our sponsors. In our Focus Update, dated December 9, 2010, we notified you about Sun Life’s enhanced claims management processes and that we would target Nova Scotia, New Brunswick and Newfoundland in the next phase of our provincial integration program. 

The next phase has arrived. Effective December 1, 2011, Sun Life will direct eligible plan members, where applicable, to these specialty programs in Nova Scotia and New Brunswick. While there are no current government-sponsored program opportunities in Newfoundland today, we will continue to monitor this province’s activity.

How do these changes affect your benefit plan? 

Your benefit plan currently excludes the services or supplies payable or available under a government-sponsored program.  Effective December 1, 2011, the wording in both your contract and benefits booklets will change to the wording set out in the box below. 

Contractual Amendment - Integration with government programs

We will not pay for the costs of: 

  • services or supplies payable or available (regardless of any waiting list) under any government-sponsored plan or program, except as described below under Integration with government programs.

Integration with government programs

This plan will integrate with benefits payable or available under the government-sponsored plan or program (the government program).

The covered expense under this plan is that portion of the expense that is not payable or available under the government program, regardless of:

  • whether you have made an application to the government program,
  • whether coverage under this plan affects your eligibility or entitlement to any benefits under the government program, or
  • any waiting lists.


Post-contract changes in Nova Scotia and New Brunswick

This change will only affect those claiming drugs that may be eligible under the government-sponsored drug programs and will be required to apply before submitting their claims to Sun Life.

  • If integration with the government-sponsored program has not yet occurred, claims will be declined.
  • These members will also receive a letter from Sun Life, upon first decline, asking them to apply to the appropriate government-sponsored program.

Post-contract changes in British Columbia, Alberta, Saskatchewan, Manitoba, Ontario and Prince Edward Island

This contract wording change will not affect existing provincial integration processes for claimants in British Columbia, Alberta, Saskatchewan, Manitoba, Ontario and Prince Edward Island.

  • If application to the government-sponsored program has not yet occurred, claims will be paid.
  • These members will receive a letter from Sun Life, asking them to apply to the appropriate government-sponsored program.
  • To maintain existing coverage, members must notify Sun Life whether they have been approved or declined within 10 weeks of the date of the letter.

What this means to existing claimants in Nova Scotia and New Brunswick?

Prior-to-contract changes

Sun Life will contact members who have claimed for identified drugs in the past year.

  • 10 weeks prior to the change in contract, letters will be sent to these members
  • Claimants, will be asked to apply to the appropriate government-sponsored program with the assistance of their physicians, where necessary.
  • Members will then send a copy of the response letter from the government-sponsored program, with the initial Sun Life letter and response form to Sun Life, indicating they have:
    • applied to the program,
    • been rejected, or accepted, and
    • if accepted, for how long their coverage has been approved.

Please note: This Focus Update serves as an amendment to your contract effective December 1, 2011. Please file this notice with your Sun Life group contract for future reference.

Enclosed please find a member communication you can distribute to your plan members for their records. The next time you amend your benefits plan, the updated wording will be included in your contract.

Questions?

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