Ontario budget plans for free prescription medications for children and youth

As part of the 2017 Budget, Ontario is moving to make prescription medications free for children and youth.

Beginning January 1, 2018, all children and youth under 25 years old will be able to receive their prescription medications for free. Coverage will be automatic, with no upfront costs. All that is needed is their Ontario health card number and a prescription. Free prescription medication will be available to children regardless of their household income or whether they have access to private health insurance through their parents.

Currently, the province’s public drug plans cover 2.3 million seniors, and about 900,000 people on social assistance. The new program, “OHIP+”, would expand public coverage to another four million people.

Beyond the most common prescriptions, OHIP+ will give young people access to more than 4,400 drugs reimbursed under the Ontario Drug Benefit Program.

Included are medications listed under the Exceptional Access Program, at no cost. These include drugs to treat cancer and rare diseases. Prescription medications will be covered if they are listed on the Ontario Drug Benefit formulary or if they are funded through the Exceptional Access Program formulary and requested by a doctor.

The effect of OHIP+ on plan sponsors of Group Benefit Plans

How or when savings may be passed on to plan sponsors is yet to be determined. For many employers dependent children make up a small portion of total drug spend, however as drug costs for dependents under age 25 drop off the plan, plan sponsors should see some reductions in total drug spend.

As January 1, 2018 approaches, we expect further information from insurance carriers on this topic.

For additional details see:

CBC News: Ontario budget 2017: Free prescription drugs for anyone under 25, a first of its kind

Ontario News Release: Free Prescription Medications for Children and Youth Through OHIP+

RBC Launches My Benefits app

With the launch of RBC Insurance’s My Benefits app, you have easy and fast access to your group benefits plan. The RBC Insurance My Benefits app allows you to:

  • Submit health-related claims online and have them processed right away
  • Check the status of recent claims
  • View a summary of past claims
  • Reference your ID card
  • Check claims eligibility and coverage details
  • View your Health Spending Account balance
  • Locate a healthcare provider
  • Use the Drug Lookup feature to verify your coverage for specific prescription drugs
  • Receive reminders about pending claim audits
  • Plus, you’ll have easy access to value-added services and discounts, such as Perkopolis, Work-Life Employee Assistance Programand more.

    Download the app

    iPhone users:
    Go to the App Store and search for “My Benefits”. The app will appear in your search results. Click on “My Benefits” to view the app description, click on the Free button, then click on the install button.
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    Android users:

    Go to Google Play and search for “My Benefits”. The app will appear in your search results. Click on “My Benefits” to view the app description, then click on the install button.
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    What you will need when signing into My Benefits

    You will need your existing Online Group Benefits Solutions username and password.

    Where to enrol or sign in

    If you are not registered and need to enrol, click here
    To sign in or to recover your username/password, click here

    Trillium Drug Program changes


    The Ontario Ministry of Health and Long-Term Care announced it is modernizing the Trillium Drug Program (TDP) in the fall.

    The Trillium Drug Program (TDP) is a provincial government program for residents of Ontario that have high drug costs in relation to their household income.
    These changes will enhance the Health Network System (HNS) and supporting systems to allow for co-ordination of benefits (COB) between private insurance plan(s) and the TDP at the pharmacy once the initial claim has been adjudicated by the private plan(s).

    How the New Process Will Work

    Payments by the insured person towards the quarterly TDP deductible will be tracked in the HNS and once the deductible amount is met, the government payments would automatically kick in (minus a $2 copayment). There will no longer be the need to submit paper receipts to TDP during the pre-deducible stage which could save up to six weeks or more wait time in order to receive TDP benefits and reimbursement.

    This automated process will rely on the insured person to provide all of their private plan information (group, individual, veteran etc.) to the pharmacist at time of purchase. It will also rely on the pharmacist to submit the claims to all plans in the proper order, up until the insured person has reached their deductible for the quarter.

    After that, Trillium will become first payer, but only for Trillium drugs until the end of the quarter. After this, the pharmacist will revert back to the private plan(s) being first payer and Trillium being payer of last resort until the next quarterly deductible is met.

    If you have a Health Care Spending Account

    Patients with a Health Care Spending Account (HCSA) that includes drug coverage must use their entire HCSA allowance and meet their TDP quarterly deductible before they are eligible for TDP benefits.

    There are no changes to TDP regulations themselves; the program itself remains the same.

    Source: Manulife Group Benefits and Retirement Solutions

    Multi-year RBC Insurance research shows long term disability claims linked to GDP

    Research using a proprietary algorithm developed by RBC Insurance shows that group long term disability (LTD) incidence rates will rise and fall with the cyclical movement of gross domestic product (GDP). Contrary to what you may think, as GDP accelerates or the economy grows, there is an increase in the incidence of LTD claims. When GDP drops, so do the incidence of claims. Using the RBC Insurance Group LTD Forecast to predict disabilities can help businesses manage costs related to claims, retain employees and ensure adequate staffing during critical seasons, while better supporting those employees when they need it most.

    For the full article see Multi-year RBC Insurance research shows long term disability claims linked to GDP

    How will Biosimilar drugs affect your plan?

    The high cost of some drugs presents a difficult situation for plan sponsors. Plan sponsors want to provide members with access to the best treatment options while managing costs now and into the future. Biosimilar drugs have entered the Canadian market and they have the potential to deliver results at a lower cost. Health Canada has approved five biosimilars so far including a biosimilar for Remicade.

    With many biologic drug patents soon expiring, the opportunity for biosimilar drugs (also called subsequent entry biologics) to be integrated into the market is upon us.

    A biosimilar is a drug demonstrated to be highly similar to a biologic drug that is already authorized for sale. They are approved based on a comparison to a reference drug. Biosimiars may enter the market after the expiry of reference drug patents and data protection.

    Generic drugs vs. Biosimilars

    Generic drugs are small molecules that are chemically synthesized and contain identical ingredients to their brand name reference drugs. Biosimilars are not the same as generic drugs. Biologics and biosimilars are made in living cells rather than with chemicals therefore a biosimilar and its reference biologic can be shown to be similar but not identical. It should be noted as well however that while chemically produced generic drugs may use the same formula, slight changes in the manufacturing process may result in variances of the generic drug as well over subsequent batches.

    How can plan sponsors encourage use of biosimilars?

    Plan sponsors could consider supporting lower priced biosimilars by designing plans to encourage members who are starting on a biologic drug to try a biosimilar instead. Members can try a biosimilar first. If they are not successful on the biosimilar, they would then move to the brandname biologic.
    Another option could be for plans to limit reimbursement for the brand name biologic to the cost of the biosimilar (also known as maximum allowable cost).

    It needs to be noted however that biosimilars are not identical to the originator biologic drug – they are not a generic biologic. Biologics are similar but not identical. Treatment of a chronic disease may not result in increased uptake of the biosimilar but treatment for an acute condition that is regularly prescribed to new patients could see increase in the use of biosimilars.

    Regardless the increased introduction of biosimilars to the Canadian marketplace has the opportunity to provide increased options for members and decreased costs for plan sponsors.

    Health Care Providers Urge Federal Government to Not Tax Health Benefit Plans – An Update

    Updated – February 7, 2017

    Prime Minister Justin Trudeau has now said that he will NOT enact a tax on health and dental benefits. Earlier, the Liberals would not say whether they intended to tax employer-sponsored health and dental benefits.

    On December 21, 2016 the Canadian Dental Association released a news release urging the Federal Government not to tax health benefit plans.

    A coalition of health care service providers warned of the potential negative implications of taxing the premiums paid on employer-provided health and dental benefits.

    These benefits provide preventative care in services such as mental health, vision care, hearing and speech-language services, occupational therapy, prescription drug, dental care and musculoskeletal care (physiotherapy, chiropractic therapy and massage therapy). The $2.9 Billion that government currently does not collect by not taxing health and dental plans helps to incent more than $32.2 Billion in health care being delivered to Canadians.

    “Taxation of these benefits will have huge impacts on access to care,” said Ondina Love, CEO of the Canadian Dental Hygienists Association, and co-chair of HEAL, an organization representing 650,000 healthcare providers. “When benefits were subject to provincial income tax in Quebec in 1993, almost 20% of employers dropped their coverage, including up to 50% of small employers. This loss of coverage can significantly impact the lowest paid employees who will have trouble paying for drugs, dental and needed health care out of pocket.”

    “We know from experiences in Quebec, that when health and dental premiums are taxed, the number of employers offering insurance decreases,” said Dr. Karen Cohen, CEO of the Canadian Psychological Association. “Younger and healthier employees given the choice may opt out of participating. With older and sicker employees opting in, premiums will rise. Employers who continue to offer these plans may reduce coverage to control costs – this will be keenly felt because coverage limits for psychological services are often already too low to cover an evidence based amount of service.”

    According to a recent IPSOS poll:

    70% of Canadians are opposed to this plan.
    48% said they would prefer to take cash over health benefits if they were taxed at the same rate, and;
    84% would end up delaying or forgoing treatment or medication if they didn’t have coverage.
    “The current public policy approach is working as intended,” continued Love. “75% of Canadians and a total of 24 million Canadians have access to care through these benefits. The health professions standing here today are concerned about access to care for Canadians. Taking care away from millions of Canadians is certainly not the way to address fairness and equity.”

    The groups involved include:

    Canadian Association of Occupational Therapists
    Canadian Association of Optometrists
    Canadian Chiropractic Association
    Canadian Dental Association
    Canadian Dentist Hygienists Association
    Canadian Physiotherapy Association
    Canadian Psychological Association
    Dietitians of Canada
    Speech-Language & Audiology Canada

    We too are against taxing premiums for health and dental to employees.

    How your disability plan will be impacted by the shortened EI waiting period

    Effective January 1, 2017 the Government of Canada is reducing the waiting period for Employment Insurance (EI) benefits, from 14 days to 7 days. The change will impact claimants whose date of disability occurs after January 1. The 15-week duration of EI benefits isn’t changing.

    how-your-disability-plan-will-be-impacted-by-the-shortened-ei-waiting-period

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    Specialty Drugs and Plan Sustainability

    Where are we on the increase cost of drugs in Canada?


    This whole issue has sort of crept up on Group Benefit Plan providers.
    Since 2013 the use of Specialty drugs have changed. Before 2013 Specialty drugs were seen more as experimental drugs.
    Now they make up 20% of the drug costs in Canada while traditional drugs have actually gone down by 1%. Meanwhile the actual number of plan members these drugs help amount to .7% of the entire insured population.

    Almost 60% of new drugs approved in Canada have been Specialty drugs. Currently for example there are 218 new Cancer and immune drugs about to be approved. There are 58 Phase 3 or above and 160 ready to approve.

    What Specialty Drugs mean to Plan Sponsors


    When a Plan Sponsor looks at their top 50 drugs claimed by amount spent, they will probably see Humira, Harvoni or Remicade on their list. Harvoni has gone from paid claims in 2014 of $3 million dollars to $42 million in 2015.

    Plan Sponsors have to come to the terms with alternatives. The easiest is if your plan does not currently have a large claimant then apply an annual spend on drugs of $5,000 to control the cost.
    Yes, this may eventually affect some of your members but it protects your plan from becoming unaffordable and the pooling charges going out of control.

    Talk to us about your options.

    202,400 Canadians will be diagnosed with cancer this year

    The Canadian Cancer Society has released a report stating that an estimated 202,400 new cases of cancer will occur in Canada in 2016. More than half of all new cases will be prostate, breast, lung and colorectal cancers, and an estimated 2 in 5 Canadians are expected to be diagnosed with cancer in their lifetimes.
    Employers may need to consider the cancer medications available to employees currently in their plans to determine if new medications should be offered. Additional support such as counselling should also be considered. The Canadian Cancer Society points out that “the Cancer experience presents many physical, emotional and spiritual challenges that can persist long after the disease is treated.”
    Another consideration is employees who need to take time off to care for a loved one with Cancer.