BENEFIT REPORT
BENEFIT REPORT NEWSLETTER | FALL 2013 | WWW.CLAC.CA
IMPORTANT CHANGES TO YOUR CLAC GROUP BENEFIT PLAN MANDATORY GENERIC SUBSTITUTION PROGRAM Benefits of generic drugs
Generic drugs are clinically identical to the counterpart brand name drug with the same active ingredients, and they usually cost significantly less. There is generally no difference in the quality, purity, effectiveness, or safety between generic and brand name drugs, so your level of treatment is fully maintained when using a generic equivalent.
Generic drug substitution
LIFE INSURANCE/AD&D ENHANCEMENTS Please be advised that effective November 1, 2013, your life insurance and AD&D coverage has increased on most plans. The table below outlines the changes.
Plan Name Prior Coverage
Coverage effective Nov. 1, 2013
Gold Plan
$60,000
$100,000
As noted in previous newsletters, generic drug substitution is a widespread cost-saving measure on drug plans, including the CLAC group benefit plan. This means that in most instances when a doctor prescribes a drug, the pharmacist dispenses the lowest priced equivalent (usually the generic) version of that drug if one is available. However, up until now, your doctor could indicate “no substitution” on your prescription and you would be reimbursed for the brand name drug.
Gold Plus Plan $60,000
$100,000
Gold Plus $60,000 Enhanced Plan
$100,000
Changes effective January 1, 2014
Premium Plan
$60,000
$100,000
Mining Plan
$150,000
$150,000
Service Plan
$40,000
$50,000
Sun Life will reimburse the cost of the lowest priced equivalent drug (usually the generic). This means that even when a doctor writes “no substitution” on your prescription, you will be reimbursed for the lowest priced equivalent. You can still purchase the higher-priced (usually brand name) drug, but your reimbursement will reflect the cost of the lower priced drug.
Please contact the CLAC Benefit Administration office if you have any questions about this change.
(continued on next page)
Western Benefits
Follow CLAC:
MANDATORY GENERIC SUBSTITUTION PROGRAM (continued) What you can do?
Talk to your doctor or pharmacist about whether a lower cost equivalent exists for any drugs you are currently taking. Remember, you will not be fully reimbursed for a drug if a lower priced (often a generic) equivalent exists.
If you currently have a “no substitution” prescription
If your doctor previously wrote “no substitution” on your prescription, the pharmacist must provide the brand drug. However, with the change to your plan, your reimbursement will be cut back to the lowest priced equivalent. You have several options: 1. To receive the lowest priced equivalent drug, your doctor will need to remove the “no substitution” from your prescription to allow the pharmacist to fill your prescription with the generic drug and to process your claim. 2. You may apply for an exception from Sun Life if there is a medical reason why you need the brand drug.
PRIOR AUTHORIZATION PROGRAM The prior authorization program requires that coverage for certain drug therapies is pre-approved based on medical criteria. It can help manage costs in a small number of cases where very expensive drugs are used. It only affects some drugs within selected categories, not every prescription you and/or your dependents may need. This program will come into effect on January 1, 2014.
3. You may continue to receive the brand drug and pay the difference out of pocket yourself.
Applying for an exception
We want to ensure that you receive the brand name drug if you medically require it. To do so, you and your doctor will need to complete a Drug Exception Application form. Your doctor must complete the section of the form that asks for the medical reasons for the request. It takes about five business days from when Sun Life receives the exception form from you to when you will receive a decision regarding approval for the brand. If your exception request is approved by Sun Life, the plan will cover the cost of the brand name drug. Sun Life may request that you resubmit the exception request form in the future. The form can be obtained by calling the CLAC Benefit Administration office or from Sun Life by calling 1–800–661–7334 or visiting www.mysunlife.ca.
DRUG SUBSTITUTION LIMIT Effective January 1, 2014, charges in excess of the lowest priced equivalent drug will not be covered unless specifically approved by Sun Life. To assess the medical necessity of a higher priced drug, Sun Life will require you and your doctor to complete and submit an exception form.
Which drugs are included?
You can get a list of the specific drugs that are part of the prior authorization program by visiting www.mysunlife.ca. Prior authorization may be required for drugs used to treat the following conditions: • Multiple sclerosis • Pulmonary arterial hypertension • Lupus • Rare diseases • Muscle-nerve disorders • Cancer • Asthma • Osteoporosis A category of drugs called biologics also requires prior authorization. Biologics are used to treat conditions such as: • Rheumatoid arthritis • Crohn’s disease • Psoriatic arthritis • Ankylosing spondylitis • Plaque psoriasis Visit www.mysunlife.ca for more information.
DID YOU KNOW? The average claim on brand name drugs is approximately $72 versus only $27 for generics. Switching to generic drugs can quickly result in savings for you and your plan and helps in keeping your drug plan sustainable and available for years to come.
HOW DOES THE PRIOR AUTHORIZATION PROGRAM WORK? If the drug your doctor recommends requires prior authorization, you will need to send Sun Life a completed Prior Authorization form before filling your prescription.
FOR BOTH NON-BIOLOGICS AND BIOLOGICS Sun Life will review your completed Prior Authorization form request within five business days of receipt and let you know in writing if you are approved. Once you are approved for a prior autho-
FOR BIOLOGICS For some categories of biologic drugs, there is a preferred drug. The preferred drug is selected based on expert opinion concerning factors such as safety, cost, and efficacy. You need to try the preferred drug before you can apply for reimbursement for another drug in that category, unless you are not able to take the
rization drug, you are approved indefinitely; you do not have to re-submit a form each time for that specific drug. If the request is not approved, you can still use the drug your doctor has recommended, but it will not be reimbursed by your drug plan.
preferred drug because of a pre-existing condition. If this preferred drug does not improve your condition, you and your doctor can submit a Prior Authorization form for coverage for a different drug that your doctor recommends for you.
LET YOUR DOCTOR KNOW The next time you visit your doctor, let him or her know about the prior authorization program and take a moment to talk about the authorization process.
FAQ What if I’m already taking one of the impacted drugs?
If you are taking one of the drugs included in the prior authorization program in the 120 days before the program begins, you don’t need to apply for approval. You will be considered pre-approved for reimbursement if you are being reimbursed now for the drug.
How do I apply for prior authorization? If you are prescribed a drug that requires you to apply for prior authorization, you and your doctor should complete and submit a Prior Authorization form to Sun Life.
Does my plan cover the cost for my doctor to complete the Prior Authorization form? No, it doesn’t.
Where do I find a Prior Authorization form?
Simply call the CLAC Benefit Administration office or visit www.mysunlife.ca. You’ll find the form and a list of the impacted drugs by selecting Prior Authorization Drug List and Forms from the Group Benefits menu at the top of the page.
(continued on next page)
CONTACT INFORMATION
FAQ (continued) If I’m approved for a drug, do I have to submit a form every time I need the prescription renewed?
Once you are approved, you are approved indefinitely for that drug. You do not have to re-submit a form each time.
If I’m not approved for a drug, can I still take the drug my doctor recommends? Yes, you can, but it will not be reimbursed by your drug plan.
How will I know if I have to apply for prior authorization?
If you have one of the conditions listed, you may wish to review the prior authorization drug list by going to www.mysunlife.ca and selecting Prior Authorization Drug List and Forms from the Group Benefits menu at the top of the page. If you are not aware of the drugs that require approval and you take a prescription to the pharmacy for one of these drugs, the pharmacist will advise you if the drug needs prior authorization. You may purchase the drug at that time, or you can complete the Sun Life form and request approval before purchasing it.
CLAC BENEFIT ADMINISTRATION OFFICE 14920 118 Ave. Edmonton, AB T5V 1B8 Telephone: 780–454–6181 Toll Free: 1–888–600–2522 Facsimile: 780–454–6180 [email protected]
SUN LIFE Telephone: 1–800–661–7334 www.sunlife.ca/member
CERIDIAN LIFEWORKS Telephone: 1–866–714–3129 www.lifeworks.com Username: clac Password: wellness
www.clac.ca
Calgary • Cambridge • Chatham • Edmonton Fort McMurray • Fort St. John • Grimsby Kelowna • Langley • Mississauga • Ottawa Prince George • Saskatoon • Sudbury • Winnipeg
IMPORTANT CHANGES TO YOUR CLAC GROUP BENEFIT PLAN MANDATORY GENERIC SUBSTITUTION PROGRAM Benefits of generic drugs
Generic drugs are clinically identical to the counterpart brand name drug with the same active ingredients, and they usually cost significantly less. There is generally no difference in the quality, purity, effectiveness, or safety between generic and brand name drugs, so your level of treatment is fully maintained when using a generic equivalent.
Generic drug substitution
LIFE INSURANCE/AD&D ENHANCEMENTS Please be advised that effective November 1, 2013, your life insurance and AD&D coverage has increased on most plans. The table below outlines the changes.
Plan Name Prior Coverage
Coverage effective Nov. 1, 2013
Gold Plan
$60,000
$100,000
As noted in previous newsletters, generic drug substitution is a widespread cost-saving measure on drug plans, including the CLAC group benefit plan. This means that in most instances when a doctor prescribes a drug, the pharmacist dispenses the lowest priced equivalent (usually the generic) version of that drug if one is available. However, up until now, your doctor could indicate “no substitution” on your prescription and you would be reimbursed for the brand name drug.
Gold Plus Plan $60,000
$100,000
Gold Plus $60,000 Enhanced Plan
$100,000
Changes effective January 1, 2014
Premium Plan
$60,000
$100,000
Mining Plan
$150,000
$150,000
Service Plan
$40,000
$50,000
Sun Life will reimburse the cost of the lowest priced equivalent drug (usually the generic). This means that even when a doctor writes “no substitution” on your prescription, you will be reimbursed for the lowest priced equivalent. You can still purchase the higher-priced (usually brand name) drug, but your reimbursement will reflect the cost of the lower priced drug.
Please contact the CLAC Benefit Administration office if you have any questions about this change.
(continued on next page)
Western Benefits
Follow CLAC:
MANDATORY GENERIC SUBSTITUTION PROGRAM (continued) What you can do?
Talk to your doctor or pharmacist about whether a lower cost equivalent exists for any drugs you are currently taking. Remember, you will not be fully reimbursed for a drug if a lower priced (often a generic) equivalent exists.
If you currently have a “no substitution” prescription
If your doctor previously wrote “no substitution” on your prescription, the pharmacist must provide the brand drug. However, with the change to your plan, your reimbursement will be cut back to the lowest priced equivalent. You have several options: 1. To receive the lowest priced equivalent drug, your doctor will need to remove the “no substitution” from your prescription to allow the pharmacist to fill your prescription with the generic drug and to process your claim. 2. You may apply for an exception from Sun Life if there is a medical reason why you need the brand drug.
PRIOR AUTHORIZATION PROGRAM The prior authorization program requires that coverage for certain drug therapies is pre-approved based on medical criteria. It can help manage costs in a small number of cases where very expensive drugs are used. It only affects some drugs within selected categories, not every prescription you and/or your dependents may need. This program will come into effect on January 1, 2014.
3. You may continue to receive the brand drug and pay the difference out of pocket yourself.
Applying for an exception
We want to ensure that you receive the brand name drug if you medically require it. To do so, you and your doctor will need to complete a Drug Exception Application form. Your doctor must complete the section of the form that asks for the medical reasons for the request. It takes about five business days from when Sun Life receives the exception form from you to when you will receive a decision regarding approval for the brand. If your exception request is approved by Sun Life, the plan will cover the cost of the brand name drug. Sun Life may request that you resubmit the exception request form in the future. The form can be obtained by calling the CLAC Benefit Administration office or from Sun Life by calling 1–800–661–7334 or visiting www.mysunlife.ca.
DRUG SUBSTITUTION LIMIT Effective January 1, 2014, charges in excess of the lowest priced equivalent drug will not be covered unless specifically approved by Sun Life. To assess the medical necessity of a higher priced drug, Sun Life will require you and your doctor to complete and submit an exception form.
Which drugs are included?
You can get a list of the specific drugs that are part of the prior authorization program by visiting www.mysunlife.ca. Prior authorization may be required for drugs used to treat the following conditions: • Multiple sclerosis • Pulmonary arterial hypertension • Lupus • Rare diseases • Muscle-nerve disorders • Cancer • Asthma • Osteoporosis A category of drugs called biologics also requires prior authorization. Biologics are used to treat conditions such as: • Rheumatoid arthritis • Crohn’s disease • Psoriatic arthritis • Ankylosing spondylitis • Plaque psoriasis Visit www.mysunlife.ca for more information.
DID YOU KNOW? The average claim on brand name drugs is approximately $72 versus only $27 for generics. Switching to generic drugs can quickly result in savings for you and your plan and helps in keeping your drug plan sustainable and available for years to come.
HOW DOES THE PRIOR AUTHORIZATION PROGRAM WORK? If the drug your doctor recommends requires prior authorization, you will need to send Sun Life a completed Prior Authorization form before filling your prescription.
FOR BOTH NON-BIOLOGICS AND BIOLOGICS Sun Life will review your completed Prior Authorization form request within five business days of receipt and let you know in writing if you are approved. Once you are approved for a prior autho-
FOR BIOLOGICS For some categories of biologic drugs, there is a preferred drug. The preferred drug is selected based on expert opinion concerning factors such as safety, cost, and efficacy. You need to try the preferred drug before you can apply for reimbursement for another drug in that category, unless you are not able to take the
rization drug, you are approved indefinitely; you do not have to re-submit a form each time for that specific drug. If the request is not approved, you can still use the drug your doctor has recommended, but it will not be reimbursed by your drug plan.
preferred drug because of a pre-existing condition. If this preferred drug does not improve your condition, you and your doctor can submit a Prior Authorization form for coverage for a different drug that your doctor recommends for you.
LET YOUR DOCTOR KNOW The next time you visit your doctor, let him or her know about the prior authorization program and take a moment to talk about the authorization process.
FAQ What if I’m already taking one of the impacted drugs?
If you are taking one of the drugs included in the prior authorization program in the 120 days before the program begins, you don’t need to apply for approval. You will be considered pre-approved for reimbursement if you are being reimbursed now for the drug.
How do I apply for prior authorization? If you are prescribed a drug that requires you to apply for prior authorization, you and your doctor should complete and submit a Prior Authorization form to Sun Life.
Does my plan cover the cost for my doctor to complete the Prior Authorization form? No, it doesn’t.
Where do I find a Prior Authorization form?
Simply call the CLAC Benefit Administration office or visit www.mysunlife.ca. You’ll find the form and a list of the impacted drugs by selecting Prior Authorization Drug List and Forms from the Group Benefits menu at the top of the page.
(continued on next page)
CONTACT INFORMATION
FAQ (continued) If I’m approved for a drug, do I have to submit a form every time I need the prescription renewed?
Once you are approved, you are approved indefinitely for that drug. You do not have to re-submit a form each time.
If I’m not approved for a drug, can I still take the drug my doctor recommends? Yes, you can, but it will not be reimbursed by your drug plan.
How will I know if I have to apply for prior authorization?
If you have one of the conditions listed, you may wish to review the prior authorization drug list by going to www.mysunlife.ca and selecting Prior Authorization Drug List and Forms from the Group Benefits menu at the top of the page. If you are not aware of the drugs that require approval and you take a prescription to the pharmacy for one of these drugs, the pharmacist will advise you if the drug needs prior authorization. You may purchase the drug at that time, or you can complete the Sun Life form and request approval before purchasing it.
CLAC BENEFIT ADMINISTRATION OFFICE 14920 118 Ave. Edmonton, AB T5V 1B8 Telephone: 780–454–6181 Toll Free: 1–888–600–2522 Facsimile: 780–454–6180 [email protected]
SUN LIFE Telephone: 1–800–661–7334 www.sunlife.ca/member
CERIDIAN LIFEWORKS Telephone: 1–866–714–3129 www.lifeworks.com Username: clac Password: wellness
www.clac.ca
Calgary • Cambridge • Chatham • Edmonton Fort McMurray • Fort St. John • Grimsby Kelowna • Langley • Mississauga • Ottawa Prince George • Saskatoon • Sudbury • Winnipeg
