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Are My Prescriptions Covered?

Gary Valcour

Tuesday, June 17, 2014

Understanding your Benefits

Guest Blogger - Peter Bocking, GBA  Employee Benefits Consultant, Hardiman Mount & Associates

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 comes 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 3,500 to 7,500 items. Privately developed formularies cover between 6,200 and 6,700 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 tablet 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?  Get some professional help from a qualified employee benefits consultant. 

Excuse Me

Gary Valcour

Friday, January 31, 2014

Should Doctor's Notes be Needed for Sick Days?

What might seem to many in the health care field to be a settled question was nevertheless raised afresh by Dr. James Aw in an article in the National Post on January 28, 2014. 

Dr. Aw, who is the medical director of a leading private health clinic in Toronto, notes that NFL star place kicker, Matt Prater, was ordered by his Denver Bronco’s coach, John Fox, to stay at home during the first three days of practice for the Super Bowl rather than risk infecting his teammates with whatever bug had caused him to fall ill.

The decision by Coach Fox has spawned a lot of discussion beyond the handicapping for the Super Bowl.  Dr. Aw observes that Dr. Scott Wooder, president of the Ontario Medical Association, released a flu-season reminder earlier in January and that reminder included the assertion that bosses should not require sick notes from employees. The rationale, according to Dr. Aw was that policies that require sick employees to justify their absence with notes, forces “patients into the doctor’s office when they are sick, which only encourages the spread of germs to those in the waiting room.”

Contrary opinions followed swiftly from other quarters most notably from employment lawyers.  Obviously, this is an issue that can plague employers and benefit plan providers as well as the employees who are suffering from a nasty flu bug.  Both sides have seen position papers written in support of their assertions and both sides have merit in many of their arguments. 

What is interesting about this particular situation is the NFL leading the charge in employee/workplace health and safety – a position for which most would argue they have not traditionally been leaders.

For more on the debate read the article here:

Peeking Behind the Curtain

Gary Valcour

Tuesday, January 21, 2014

Transparency in Healthcare

A few weeks ago, I did a post called Three Modest Proposals.  While I doubt there’s any connection, I found it interesting to see an article in the National Post on January 14, 2014 in which one of those proposals was discussed at some length.  The idea has many names but one that seems to say the most is “burden statement”.  It suggests a kind of invoice or list of the various costs a patient or family has put on the health care system.

The article notes that when Belinda Stronach ran for leader of the federal Conservative party her key idea on health care reform was to “sensitize” voters to the true costs of treatment by providing a kind of invoice of the services they’d used.  The article points out that Tony Clement, when he was provincial Minister of Health in Ontario, had started a pilot project to measure the effectiveness of having doctors present itemized statements (not bills) to their patients. 

While this concept has actually be tried in a few jurisdictions without much apparent success, it is such a powerful idea that it really refuses to die.  Now it is being resurrected by the chief executive of the Windsor Regional Hospital. 

With healthcare a $50 Billion dollar industry and provinces spending four out of every ten dollars on healthcare and anticipating that percentage to increase, any reasonable ideas to get a handle on costs is worth considering. 

All of this “public” money is, of course, in addition to all the “private” money paid by employers to insurers for benefit plans and augmented by individual insurance plans or just plain payments from people who aren’t able to find a plan they can afford. 

So, whether it’s provincial health plans, local hospitals or employer sponsored plans, the need for a greater understanding of actual health care costs and their primary drivers is both evident and growing. 

For more on this topic catch the article here:


Want a Benefit Plan – Show us your DNA

Gary Valcour

Wednesday, January 08, 2014

Privacy Rights vs Insurance Realities

Robert L. Brown, an expert advisor with and a fellow with the Canadian Institute of Actuaries, has an interesting article in the December 18, 2013 edition of the National Post. 

According to Brown, while the Province of Ontario is proposing a change to the Ontario Human Rights Code aimed at protecting people’s genetic information from being used by insurance companies and employers, large insurance companies may soon argue that they have a fair claim to a person's genetic information. In Brown’s view, the Insurance Companies will be right.

While the move to protect privacy rights seems to be a no-brainer, the actual results could lead to some dramatic unintended consequences.

To quote Mr. Brown, “The insurance mechanism is dependent on being able to group like risks into underwriting classes and then price them according to the expected costs they bring to their pool. Today, young drivers pay more than mature drivers for car insurance. Smokers pay more than non-smokers for life insurance. This is based on huge data pools showing connections between certain personal traits and ultimate claims (either as to timing or size of claim).”

He goes on to say that “For the contract to be fair, the insurer must be allowed to gather an equal understanding of the risk the applicant is going to bring to the insurance pool. Otherwise, poorer risks will cause claim payouts to be larger or to be paid earlier, thus raising the average claim cost and inevitably raising the premiums to be paid by all.”

If the Insurance companies cannot reasonably turn a profit the whole world of private insurance all its benefits is in danger of massive change and possibly even disappearing for some types of benefits. 

A good article and well worth the read for the additional details and the alternatives presented.

Read it here: 

The Dr. Is In ( your Tablet!)

Gary Valcour

Friday, December 27, 2013

The Future of HealthCare?

A new service called “Doctor On Demand” was launched on December 10, 2013 and promises to put a whole new face on the practice of medicine – even if the face is on your computer screen, iPhone or tablet.  This innovation puts a new spin on the all but forgotten practice of a Doctor making house calls.  In this case the house call is virtual and the Doctor comes to you through the magic of modern communication technology.

The new service is available in 15 U.S. states for a price of $40 per video call — a price the co-founders believe puts Doctor on Demand on par with most insurance co-pays and cheaper than most urgent care. The idea is to make a quality, experienced physician available to any consumer for just $40.

The Province of Ontario and others introduced the concept of TeleHealth several years ago as a way of dealing with Doctor shortages in many communities.  However, that program would seem to be a dinosaur compared to this new venture.  And, given the state of medicine in Canada, it seems unlikely we’ll see it introduced here anytime soon.  Still, for Snow Birds and frequent visitors to the U.S., this may be a program of some interest to Canadians.

For more information see the article here or visit the website  

What do you think?  Does this innovation have real promise?  What are the chances we’ll see it in Canada in the foreseeable future?