You may have private insurance (usually from work) for drug costs. The plan is usually from your workplace. You can check details with the insurer. You should ask the insurer or your pharmacist if the plan covers your needed medications. Some plans have annual expenditure caps, or charge an annual deductible. For many plans, you pay a percentage of your prescription costs. For example, many plans cover 80% of drug costs. In some cases, they pay the pharmacy directly on online. In other cases, you pay first and then submit claims for reimbursement. You use a standard claim form for that insurance company.
Some insurance plans revert to 100% drug coverage within the insurance fiscal year. This can happen if you submit claims that reach a total set cost. At that point, there is an upgrade in coverage. It is wise to check with your insurer or with your employer. The employer is termed the “administrator” of your insurance plan.
For some medications, the insurer requires a completed form. Your physician fills the form and submits it. Usually, the physician or pharmacist understands when this form is essential. If uncertain, the insurance company can tell you. You would contact the insurer and provide the Drug Identification Number (DIN) for the medication and dosage. The insurer can send you the application form for that drug. The term used is usually “pre-authorization” or “pre-approval”.
Persons living with HIV/AIDS often worry about where information goes. Does the insurer tell the employer about your medication names and uses, for example? In actuality, this does not occur. The insurance company processes claims. In-house health providers consult on eligibility. The insurance company is essentially bound by confidentiality. Most employers purchase employee insurance plans based on “catastrophic cost pooling”. This means that they group with large numbers of other employers. As a result, there is an averaging or spread-out of the costs of any one person. Expensive drugs do not show on the “radar” for you. This is sometimes called “flattening or leveling the distribution” of medication costs. It is virtually impossible that they “flag” an individual for high utilization. In some instances, the employer may receive information that the total drug costs increased for the employee group. Sometimes insurers set their premiums on these patterns. However, the employer would not know specific employee details. The employer might make an assumption based on the start dates or termination dates of employees, but they are not “tipped off” by the insurer.
It is now very rare that an employer requires submitting drug claims to a supervisor or a Human Resources staff-person at your place of work. The insurance company heavily discourages setting up that kind of arrangement. If you are told to submit your claims at work, and that is uncomfortable or worrisome for you, try to consult someone. You can speak to an experienced Social Worker at your treatment clinic or your local AIDS Service Organization.
Your part of the drug bill may be expensive. This is called the non-insured portion. It may be difficult to budget your personal funds for these expenses. In such cases, you can apply for the Trillium Drug Program (TDP). If your portion of the cost of medications exceeds 4% or your income, it might be beneficial to use Trillium Drug Program along with the insurance. You can find details on the TDP beginning on page 5 of this guide and in the two appendices at the end.
Your private insurance may have a “health spending account” or “flexible benefits” arrangement. If so, the drug cost benefits are grouped into the same “benefit fund envelope” as the other extended health care perks. You risk tapping out the benefits for expensive HIV-related medications. Then you might lose access to other important health-related benefits in the insurance plan. Nevertheless, you still must report and use the insurance with Trillium Drug Program. This applies if you are using the TDP for supplementary assistance. It is OK to first tap into your health spending account for non-drug expenses. You can try to do that prior to utilizing the account for medications. This strategy involves planning certain expenditures early in the insurance fiscal year. For example, you can time dental work or eyeglasses immediately following the point of annual fund replenishing.
Another way to conserve private insurance funding is timing of expense claims to insurance and Trillium Drug Program. Get the receipt for your percentage of the drug costs. Submit claims to TDP immediately. Do it as soon as you acquire your receipt or your insurance statement. In any given TDP fiscal quarter, once you reach your deductible you can use TDP fully. Sometimes, a TDP enrollee will see that happen by the second month of a quarter. It will happen in the third month of a quarter for TDP enrollees who do not reach the deductible until the second month of the quarter. This will, of course, vary if not all drugs in a given month are purchased simultaneously. When TDP has officially recognized you attained or surpassed your deductible for the quarter, simply use your OHIP card at the pharmacy for full coverage for the remainder of the quarter. You can repeat the strategy and procedure each TDP fiscal quarter. The quarters begin the first of August, November, February and May. You can “do the math” yourself, or contact TDP to see if you reached your deductible. This strategy can also help reduce the occasions you have to “front” your out-of-pocket non-insured portion and wait for the reimbursement from TDP.
Most private insurance plans block a refill earlier than a set post-dispensing period. Most plans require a proportion of the previous coverage period to have elapsed. Then they allow for refill. Usually two-thirds or 70% of the period must elapse. For example, let’s say you obtain a 30-day supply of medication. You attempt to fill the subsequent 30-day supply before 21 days have elapsed. The insurer will likely reject the claim. This can particularly complicate matters if you are using insurance in combination with Trillium Drug program.
For long-term medications, many insurers will eventually allow a larger supply to be dispensed at any one time. This is on a drug-by-drug basis. For example, you may start a medication at a 30-day supply. If it is refilled a few times, the insurer will recognize it as a maintenance-type drug. At that point, it will be possible to get 60-day or sometimes 90-day supplies. Sometimes this is termed “transition from an acute use drug to a maintenance use drug”. The same refill blocking rules apply. For example, 60 days of a 90-day supply must elapse. Then you can refill the next 90-day supply.
In general, it is a good idea to be familiar with the above details of your insurance plan. For example, if you plan time outside of Canada you would then know how to strategize. Without the planning, you may find yourself stuck without the supply you need.