Individuals with a private drug plan who have high out-of-pocket prescription drug claim expenses will have the option to apply to the Trillium Drug Program.
What is the impact on plan members?
With this change to OHIP+ eligibility, individuals with private insurance currently covered under OHIP+ will need to revert to their private plan to claim drug expenses, as they did before the launch of the OHIP+ program. As of April 1, 2019, our system will be changed to ensure we comply with this requirement. Pharmacists are going to be responsible for confirming with the patient whether they have a private drug plan. If yes, the pharmacist will need to change the patient’s payer from OHIP+ to your plan. Once this is done, the claim will be processed. In most cases, this change will be seamless to members, as the overall experience will be the same as it was before the launch of OHIP+.
How will we manage claimants who are getting coverage through OHIP+ for a drug that requires a prior approval from Sun Life?
Individuals who already went through the process and have an active approval on file won’t have any action to take. Our system changes will ensure that as of April 1, 2019, claims are processed by Sun Life according to plan parameters. The pharmacy will be notified of a pay-direct drug (PDD) claim payment via the system.
Individuals who do not have an active approval on file will be transitioned to the Sun Life plan. A process was developed in close collaboration with CLHIA, the Ministry of Health and Long-Term Care (MOHLTC) and the pharmacy community. Here are key details you should be aware of:
- Effective April 1, 2019, the transition period will be in place for 6 months. During this period, members will receive coverage through their private insurer while collecting necessary clinical information from their doctor to go through the prior approval process. This timeline is the same for all CLHIA member insurance companies.
- During the transition, members will be asked to submit proof of OHIP+ payment to Sun Life in order for a claim to be considered under their plan. CLHIA has obtained support from the pharmacy community that it will provide assistance to all transitioning members and has developed a standardized pharmacy form that will help collect the necessary information. Also, CLHIA created a process for the pharmacy to submit the information to private insurers.
- The pharmacist will provide the form to the member who will need to submit it to Sun Life via web, mobile or paper.
- Once we receive the information, we’ll process the details on our system. If the drug is eligible under the plan and the patient provided proof of the OHIP+ payment, we’ll start the 6-month transition coverage and guide the member through the steps of the prior approval process.
- Claim payments issued by Sun Life will be done according to plan parameters.
More details on OHIP+
- To provide you answers to questions you may have on the OHIP+ program changes, we have created this FAQ.
- To help answer questions your employees may have on OHIP+, we have developed a plan member communication with an additional FAQ attached to it.
- In addition, we’ll communicate by letter with each plan member who requires transitional coverage, letting them know about the 6-month period during which, they will need to provide clinical details to support the continuation of coverage beyond transition.
Please refer to the detailed FAQs for further information or contact your Sun Life Financial group benefits representative.