February 2006 Focus Update #91

In this issue...


New drug claims payment threshold
Helping plan sponsors better manage the drug claim costs of Manitoba and Saskatchewan plan members

We’re making a change to our drug claims process that will help to ensure drug claims for plan members in Manitoba and Saskatchewan are properly coordinated with the drug benefit programs in those provinces. Effective March 1, 2006, we’ll introduce a drug claims payment threshold for Manitoba and Saskatchewan plan members. For members under age 65, the threshold will be $1,200. For members 65 and over, the threshold will be $1,000. Both Manitoba Pharmacare and the Saskatchewan Special Support Program (SSP) have an income-based eligibility requirement for coverage. The level of a family's income determines how much financial assistance the government will provide for prescription drugs. The lower a family’s income, the more assistance they receive. To be eligible for Manitoba Pharmacare and Special Support Program benefits, all Manitoba and Saskatchewan residents have to formally register and divulge their income tax information. Residents who don’t register are automatically assigned the highest deductible level. Because registration for these programs is not mandatory, we expect that many plan members have not registered. If a group benefit plan member does not register, this has the potential to impact drug plan costs, especially if a plan member has high drug costs.

 

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Coordinating claims with provincial programs while encouraging member enrolment

 

The introduction of a drug claims payment threshold will help us to better manage drug claim costs for plan members living in Manitoba and Saskatchewan. Having the threshold in place will help us properly coordinate plan members’ reimbursement and pay-direct drug claims with Manitoba Pharmacare and the Saskatchewan Special Support Program. As well, as part of the administration process, we’ll encourage plan members to register for their respective program if they haven’t already done so. Both will help to ensure that you are not paying for drug costs that are eligible under a provincial program.

 

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How the threshold works

Eligible drug claims we receive up to the threshold will be paid as they are now. As plan members and their families approach their threshold, we will notify the member that we need confirmation of their Manitoba Pharmacare or Special Support Program registration if they haven’t already provided it. Without providing us with registration confirmation, the member may experience a disruption in claims service after reaching the threshold. Only claims for drugs that are on the Saskatchewan and Manitoba formularies will be applied towards the threshold limit.

 

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What you can do

 

To ensure that all eligible plan members have registered for eligible programs, you may want to encourage member registration and make members aware of the new claims payment threshold. The attached communication will help you share this information with your plan members.

 

Program registration details and other information are available on the Saskatchewan government's website at http://www.health.gov.sk.ca/ps_drug_plan_special.html and the Manitoba government’s website at http://www.gov.mb.ca/health/pharmacare/. Plan members may submit proof of registration (i.e. the letter from their provincial program) with their claims or forward it to the Sun Life Financial group benefits claims office nearest them.

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Important information for plan members residing in Manitoba and Saskatchewan

 

Effective March 1, 2006, Sun Life Financial is introducing a new drug claims process that will coordinate your drugs claims with the Manitoba Pharmacare or the Saskatchewan Special Support Program.

 

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How does it work?

 

Eligibility for coverage under your provincial government program is based on family income and family prescription drug costs. As such, the amount you are covered for varies. That’s why it’s important for you to register for your provincial program. Registration ensures appropriate deductibles are applied and claims are properly coordinated between your provincial plan and your group benefits plan. As of March 1, 2006, Sun Life Financial’s claim assessment process will be revised to include a claims payment threshold limit. If you are under 65, the threshold will be $1,200. If you are 65 or over 65, the threshold will be $1,000.This means that while we will continue to pay your eligible drug claims, as you and your family near the threshold limit stated above, we will notify you that you need to confirm with us that you are registered for either the Saskatchewan Special Support Program or Manitoba Pharmacare. The letter of confirmation you receive from your provincial program is a necessary element in our new claiming process. If you don’t provide us with this confirmation, you may experience a disruption in claims service after reaching the threshold.

 

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Reminding you to register for your provincial program

  • If you use a drug card at the pharmacy to pay for your claims, the pharmacist will receive one of the following online messages to pass on to you right at the counter:

 

If the amount of the claim submitted + the claims paid to date total:

The claim will be:

Message received:

LESS than the $1000/ $1200 threshold limit

PAID

(if eligible)

Please register with the provincial plan

90% – 100% of the $1000/ $1200 threshold limit

PAID

(if eligible)

Failure to enrol (in provincial plan) may suspend payment

size=2 face="Arial, Helvetica, sans-serif">OVER the $1000/$1200 threshold limit

DECLINED

Insurer requires provincial enrolment

 

 

 

  • If you submit your drug claims using a claim form, messages similar to the ones above will appear on your claim payment statement.
    Registration details are available on the Saskatchewan government's website at Special Support and the Manitoba government’s website at Manitoba Health. You may submit proof of your registration (i.e. the letter from your provincial program) with a claim or to your nearest claims office. For more information, please contact your plan administrator.

 

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