Are my Precriptions Covered?

As government programs change their benefits, often reducing the coverage, it’s more important than ever to understand how your group insurance plan can provide a financial safety net—especially when it come to prescription drugs.

All group health plans base their benefits on a list of eligible drugs called a formulary. Most insurance companies have several formularies available. This lets employers choose, from comprehensive plans that cover most prescription drugs to more restrictive plans where only certain types of drugs are covered.

Some group plans even let the employer add or remove specific drugs to control coverage — and cost! For example, smoking cessation or erectile dysfunction drugs may be covered under some plans and not covered under others.

If you opt for the most comprehensive plan, one that includes all medications with a DIN ( Drug Identification Number), your plan will allow over 10,000 items. Such plans are not common today because the cost of these plans is typically quite high. Today’s more typical formulary would cover drugs which, by law, require a prescription—approximately 8,300 items.

With plan costs rising, many companies turn to ‘managed formularies’ with cost containment features. For example, managed formularies may pay for generic drugs, but not the additional cost of brand name versions. Some group plans use a provincial drug listing as the basis of their coverage. These cover from 3500 to 7500 items. Privately developed formularies, such as Emergis’ “National Formulary”. Cover between 5200 and 6700 DIN designated items.

Whichever formulary you choose, keep in mind that medications may have multiple DINs. That’s the case with a 200 mg tablet, a 400 mg tables and a 400 mg time release capsule, all with the same active ingredient. In some formularies, the 400 mg tablet may be covered, while the time released capsule might not.

Too many choices? Your Chambers Plan agent can help you select the right formulary for your needs.

CHOICES CHOICES CHOICES

Almost 24 million Canadians are protected by one or more life and health industry product. They get their coverage from 105 life and health insurance companies operating in Canada, where 116,000 people work to deliver insurance products and services. 51,000 of these are full-time employees and agents, while 64,000 are independent agents, working from coast to coast.

So how do you know who to go to for your group plan needs? As you look for a group plan carrier and/or an agent keep these things in mind.

First, decide what's more important to you: the company insuring the plan or the person you will be dealing with? Insurance agents who work exclusively for one company have extensive knowledge of that insurer's products. So, if you know what you want, this may be the route to go. If you're not sure, perhaps an independent agent with access to multiple insurance companies is better able to give you options to match your needs.

Second, don't let an agent start "selling" you a plan. Make sure your agent takes the time to understand your needs and objectives, then works with you to find the best coverage available for your business.

Third, as in any business, on-going "service" will be very important. Will your agent be able to help you quickly and efficiently? Will your claims be paid promptly? Ask people you know or trust for their recommendations.

Your group plan provides protection to your business's most important asset - its people. Take the time to find the best possible solution for your company.

Two KIDS

Two INCOMES

Two GROUP PLANS

Your dental bill, your spouse's chiropractor bill, your kids' prescription drugs. How do you know where to submit your claims?

If you and your spouse both have group benefits through your respective employers, insurance companies will pay health and dental benefits following a standard procedure. This process is called Coordination of Benefits and your group plan information should explain the process for you. If not, the following summarizes the industry's standard practice.

1) When you are the patient, send the claim to your plan first.

2) When your spouse is the patient, send the claim to the spouse's plan first.

3) When a dependent child is the patient, send the claim to the plan of the parent whose birthday falls earlier in the year. In situations where parents are separated/divorced, then the following order for claims submission for children applies:

i) the plan of the parent with custody of the child;

ii) the spouse of the parent with custody;

iii) the parent not having custody of the child;

iv) the spouse of the parent not having custody.

If the first plan does not pay the whole amount, send the explanation of benefits provided by the first plan along with a claim form, to the second plan. Generally, between the plans, families can be reimbursed for 100% of the eligible expenses incurred.

NEED HELP WITH YOUR COMPLICATED LIFE?

Our lives continue to get quicker and more complicated, and sometimes we don't know where to turn for help. Perhaps your group plan can help. Employee Assistance Plans (EAP's) have been a growing part of group insurance programs over recent years. Once considered a top up to comprehensive coverages, they're now common across the country. Employers consider them a solid (and affordable) investment in prevention, helping employees address issues in their lives before they take a toll at work.

The Chambers Plan has had an EAP program for the past decade. Like many of the plans in the early years, the EAP benefit focused mainly on interpersonal issues like family relationships, stress management, work-related difficulties and dependency problems.

But sometimes we need help with a broader range of topics, many reflecting changes in our society and demographics.

For example, the Chambers Plan benefits now include Eldercare resources, recognizing the large number of Canadians with concerns about senior family members. EAP staff can help employees research local options for retirement homes, home care and related support services. Parallel services are available focusing on childcare.

Employees can also call on the Chambers Plan's EAP for legal advice in the areas of family law, separation, divorce, child support and custody. Similarly, financial advice is available to help employees deal with credit card and debt management, bankruptcy, budgeting, and the financial aspects of divorce.

Employees and family members can simply pick up the phone and contact the EAP's call centre, where the caller's need is identified, and matched with local resources. The appropriate expert then provides up to 12 hours of counselling time to address the issue - and get your life back on track.

IT PAYS TO INCREASE

YOUR GROUP INSURANCE WORD POWER!

When you're in the market for a group insurance plan for your own business, you may not be familiar with terms used in the industry. Here are some general terms and concepts that will get you off to a good start.

Anniversary - This term typically refers to a specific date following the effective date of your plan's coverage that your plan is renewed. At the anniversary date, rates are typically reviewed and revised.

Census or Employee Data - Statistical data used to determine rates or benefits in a plan. This can include information such as age, sex, income, smoker/non-smoker status, or your job classification (factory worker, office employee, management).

Co-insurance - This is the provision in your group contract that states how the plan and the insured members share the costs of eligible expenses. For example, an 80% coinsurance plan would reimburse the insured for 80% ofa covered expense, with the insured paying the remaining 20% of such expenses.

Deductible - Health and dental benefits often include a deductible. A deductible is the dollar amount of the covered expense that the employee must pay before benefits become payable by the plan.

Elimination Period - This typically refers to a period of time during which an employee must be totally disabled before short term or long term disability benefits can commence.

Pre-Existing Condition - A physical and/or mental condition that exists prior to the effective date of your coverage. In some instances there may be limitations as to what the insuring companies may cover or pay if the benefits you are claiming are as a result of a pre-existing condition.

Your Chambers Plan agent is an excellent source of information about your plan and its benefits, and would be glad to assist you with any questions you may have.