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Ontario government’s plan should reduce burden of higher drug costs

By Susan Yellin | November 04 2016 01:30PM

The Ontario government is planning to roll out the co-ordination of benefits between the Trillium Drug Plan (TDP) and private insurance plans in the fall of next year, significantly reducing the financial burden of higher-cost drugs.

Menzies Jardine, senior manager with the Ontario’s Ministry of Health & Long-Term Care, told a Canadian Group Insurance Brokers (CGIB) session this week that the way the current system works is a real issue for many Ontarians who require high-cost drugs.

Those who sign up and are eligible for the TDP must pay a deductible of about 4% based on total household net income and the number of people, including dependents, who are in the home.  

Jardine said her ministry has been aware of the problems confronting ill patients and their families, including that the patient must submit paper receipts and a private insurance statement for the out-of-pocket expenses to be counted towards the TDP quarterly/annual deductible.

Long wait for benefits

Some TDP recipients with private insurance face a long wait to receive their benefits.  That can add up, she said, if the patient has a private insurance plan that may only cover, for example, $500 of what could be a $1,200-drug.

“Your private insurer is first payor so it pays $500 and then you are out of pocket for six to eight weeks by $11,500,” Jardine said. “That can be a significant burden to someone determining whether they get their medication or not.”

Payor of last resort

Once the insurance company pays out what it owes to the patient, the TDP steps in and acts as the payor of last resort.

She also said the department will be looking at enhancing its health network and supporting systems to let pharmacies submit co-ordination of benefit claims for TDP recipients with private insurance through an on-line system.

No need to submit paper receipts

This means that patients will no longer have to submit paper receipts to TDP if the pharmacy has already co-ordinated the benefits, she said.

Some other provinces already have systems that have integrated the public and private systems.

Dave Patriarche, founder of CGIB, said insurance companies associated with the Canadian Life and Health Insurance Association have been talking with Trillium about the co-ordination of plans for about a year.

A win for employers and employees

Patriarche said the decision is not only a win for employers and employees with health plans, but should also help reduce drug costs in Ontario.

He said the province has already proven it is a better negotiator than insurance companies when it comes to reducing the price of drugs, noting it brought down the price of generic drugs from about 68% of brand name to about 20%. “That’s huge.”

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