Health & Welfare Plan Changes Effective April 1st

Apr 1, 2019 | Benefits Office

Coverage for a Registered Clinical Psychologist

Effective April 1st, 2019 the coverage for charges of a duly licensed and registered clinical psychologist will be 80% to a maximum of $2,000 per insured individual per calendar year, which falls under the combined Medical/Vision Care Plan limit noted below.
Previously, the coverage for charges of a registered clinical psychologist were available under the category of Paramedical Practitioners. It is now a separate benefit with its own coverage maximum.

Vision Care Plan Change

Effective April 1st, 2019 coverage under the vision care plan will apply to insured individuals that have claimed for laser eye surgery. Insured individuals who have claimed for laser eye surgery in the past will now be eligible under the plan rules to claim for eye examinations and glasses. Please refer to your Benefits Booklet for coverage details.

Re-introduction of the Health Plan Annual Limit

Effective April 1st, 2019 the following annual limits will be placed on the health plan:
Prescription Drug Plan: $10,000 per insured individual per year
Combined Medical/Vision Care Plan: $8,000 per insured individual per year Dental Plan: $2,000 per family per year
This means that the overall maximum the plan will pay for claims to an insured individual (or family for dental claims) per year is the amount specified above for each plan.

How will this change affect me?

There is no change to the Dental Plan. With regard to the Prescription Drug and Medical/Vision Care plans, the Trustees reviewed plan usage to determine the limits the plan can afford that would affect the least number of people and provide the most protection against high cost claims. The annual limits will only impact 4% of claimants, mainly due to high cost specialty drug claims. We assure you that the decisions made by the Trustees are to protect the financial security of the Health & Welfare Plan so that all members and their immediate family can enjoy personal well- being going into the future.

Why the change?

In 2015 the Trustees removed the $5,000 annual limit per insured individual to allow for unlimited yearly benefit payments. To protect the plan against high cost claims and ensure the future sustainability of the plan, the Trustees put into effect a Stop Loss Insurance with SSQ Financial. For a reasonable premium, SSQ Financial would reimburse the plan for the portion of overall health expenses that exceed $10,000 per insured individual. These two measures would give members and their dependents the opportunity to get the most out of their benefit plan while protecting the plan assets for future benefit coverage. The first year tracked very well; there were 10 claimants that resulted in a stop loss reimbursement of $82,219.53.

Then came the growth of specialty drug costs to the plan. SSQ Financial anticipated a higher stop loss claim for 2017, so they increased the premium rate by 40%. In 2017, there were 29 claimants that resulted in a stop loss reimbursement of $422,260.20 and with it came an additional premium increase of 64.8% for 2018. The Trustees determined that the Stop Loss insurance with SSQ Financial was too expensive. The premium costs were too high. An attempt to go to market to find an insurer with better rates revealed that most insurers have decided to get out of the Stop Loss market. Those that remain have taken the underwriting approach where the premium is equal to the projected claim plus expenses. This would leave the plan fully exposed to high cost specialty drugs that would threaten the financial security of the fund. Therefore, the Trustees determined that in order to protect your health plan, the stop loss insurance will terminate on April 1st, 2019 and an annual limit will be re-introduced.

What are Specialty Drugs?

Specialty drugs are drugs used for the treatment of complex conditions and they often require special storage, handling, monitoring and administration. As a result, they are expensive. They are often referred to as biologic, biosimilar, or orphan drugs. Despite their high cost, specialty drugs represent important advancements in medicine and they can often significantly improve the quality and longevity of an individual’s life. Thankfully, specialty drugs are managed and supported by the drug manufacturer. The drug manufacturer is required to set up a patient support program. When an individual is prescribed a specialty drug, a coordinator for the patient support program will determine the coverage available through private insurance, the provincial government, and the drug manufacturer. Financial assistance programs provided by the drug manufacturer can bridge the financial gap if the drug is not fully covered by coordination between private insurance and the provincial government. Currently, each claimant on a Specialty Drug is costing the plan between $10,000 to $110,000 per year. In 2019, Canada’s drug pipeline is braced to launch more than 140 new drugs and greater than 50% of those drugs are high-cost specialty drugs. The annual cost of these specialty drugs will range from $6,400 to $704,000. Most of these drugs do not require in-hospital treatment, which means that private drug plans like ours will be the first payer once they are prescribed. These costs reinforce the need to have an annual limit on the prescription drug plan.

Express Scripts Canada Specialty Drug Program

To help manage the impact of specialty drugs costs on the plan, it is important the following measures are considered:

• Ensuring that specialty drugs are being used only by the right plan member at the right time; • Maximizing opportunities to obtain favourable pricing; and
• Supporting patient adherence to maximize treatment efficacy.

In order to achieve these measures, the Trustees are introducing the Express Scripts Canada Specialty Drug Program effective April 1st, 2019. This program is designed for people who live with complex, chronic illness and have been prescribed a specialty drug that will now require prior authorization approval.

The Express Scripts Canada Specialty Drug Program consists of three main components:

• Advocate Services – A highly skilled team specialized in navigating the avenues of financial assistance available and coordinating with the programs/plans involved on behalf of the patient.
•  Active Pharmacy – Pharmacists focused on specialty conditions that will counsel patients and dispense medications. They are available 24/7 to answer any questions or concerns you may have. Medications will be delivered to you for free to your preferred location with regular reminders so you never run out.
•  Therapeutic Resource Centre – They will develop an integrated treatment plan and a personalized health action plan through ongoing monitoring and care.

Who will be enrolled in this program?

If you or an insured family member is prescribed a specialty medication that is supported by the Express Scripts Canada Specialty Program, you will be automatically enrolled. Due to the complex treatment protocols, storage/monitoring requirements, and their cost, the distribution and dispensing of specialty drugs is different from traditional drugs. Some of the specialty drugs have closed distribution models or are required for immediate treatment, therefore they are not able to be supported by the Express Scripts Canada Specialty Program. In this case, you will be provided access to that drug and case management through the specialist when the drug is prescribed.

What happens after I’m enrolled in the Express Scripts Canada Specialty Drug Program?

When the pharmacist submits your specialty drug claim, a message will be received stating that the “Drug must be Authorized”. This means a Prior Authorization Request Form must be completed. The form can be accessed and printed by the patient, pharmacist, physician, or plan sponsor from Express Scripts Canada (ESC) website or the pharmacist may contact ESC’s call centre by telephone and request the form. When the completed Prior Authorization Request Form is returned to ESC, their prior authorization team will review it to determine whether you meet the eligibility criteria for the drug. You will be notified within two (2) business days once all required documentation is received by ESC. If approved, ESC Advocate Services will contact you for support, the ESC Pharmacy will fill and ship your medication, and the ESC Therapeutic Resource Centre will contact you for therapeutic support.

What is Prior Authorization?

Prior Authorization is used to ensure specialty drugs are only covered when prescribed for use approved by Health Canada. It is a process whereby the pharmacy team at ESC clinically review the prior authorization request forms to ensure that you meet the established criteria prior to allowing your coverage for that specialty drug.

How does Prior Authorization Work?

If a specialist is going to prescribe a specialty medication for you, advise the specialist that prior authorization is required. The specialist may have the Prior Authorization Request Forms from Express Scripts Canada on hand. If not, it is available on the ESC website:

If the specialist isn’t aware that prior authorization is required and the pharmacist receives a message stating that the “Drug must be Authorized”, the first step is to get a Prior Authorization Request Form. The pharmacist may contact ESC’s call centre by telephone on your behalf to obtain a form.

  • Fill out any required sections on the form, including your authorization to disclose health information. You must take the form to your physician to complete. If your physician charges a fee to complete the form, you are responsible for paying the fee.
  • The completed Prior Authorization form has to be returned to ESC via:
    Fax: (905) 712-6329 or mail to:
    Express Scripts Canada Clinical Services
    5770 Hurontario St., 10th Floor
    Mississauga, ON
    L5R 3G5
  • ESC clinical pharmacist evaluates the completed Prior Authorization form to ensure that you meet the established criteria. Upon receipt of a form containing all required information, it will take two (2) business days to evaluate and update your profile.
  • If the Prior Authorization is approved, ESC will update your profile to allow for payment of the drug and send you a letter indicating that the Prior Authorization has been approved.
    At this point, ESC Advocate Services will contact you for support, the ESC Pharmacy will fill and ship your medication, and the ESC Therapeutic Resource Centre will contact you for therapeutic support.

At this point, ESC Advocate Services will contact you for support, the ESC Pharmacy will fill and ship your medication, and the ESC Therapeutic Resource Centre will contact you for therapeutic support.

If you have any questions on the information in this newsletter, please contact Leslie at 709-747- 2249, ext. 308 or

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