The DDP is a drug card plan in which the claimant is reimbursed directly by Assure Claims Management, instead of Great-West Life.

GWL has given Assure the mandate to deal with pharmacies on their behalf in order to facilitate the operation of the CISVA Rx drug plan program.

With the Deferred card, the claimant is reimbursed at the earlier of these two tiers:

1. Dollar Threshold Amount = $75, for the family, or

2. Deferred Period = 30 days

1. Dollar Threshold Amount = $75, for the family

◦ If the total cost of your eligible prescription drug purchase meets or exceeds $75, at the time of purchase, claims payment is released by Assure after 7-10 business days.

2. Deferred Period = 30 days

◦ If the total cost of your eligible prescription drug purchase , at the time of purchase, is less than $75, claims payment is released by Assure after 30 days

Suggestion: sign-up for direct deposit through Member Portal so that you don’t have to wait for “snail-mail.”

Plan continues: to be a reimbursement policy only

◦ You continue to pay 100% of the expenses up front & are then reimbursed accordingly for eligible expenses

to reimburse at 80% for in-Canada, non-emergency expenses

to maintain a $25.00 annual, family deductible

to maintain the claims submission deadline as June 30th for the previous calendar year’s claims

to assess all other Extended Health claims directly by GWL

Plan change in claims submission:

◦ Rx drug claims can no longer be submitted online via

Member Portal

As we are “positively enrolled”, the Assure Card allows the individual registration of each plan member, as well as his or her dependants. With this information, the pharmacist can confirm the plan member and dependants’ eligibility and drug coverage.

Drug card can be used at all participating pharmacies, nationwide.

◦ Cards cannot be used out-of-country.

Drug cards will be issued to the following participants (if applicable):

◦ The employee (the insured)

◦ The dependent spouse

◦ Over-aged dependent child (age 22-25)

Dependent children under the age of 22 will not receive a card

1. The plan member pays 100% of the cost of his or her prescription drugs

2. At the time of purchase, the Pharmacist electronically submits claims on the member’s behalf

◦ One of the features of the deferred drug card is to greatly reduce (nearly eliminate) paper claims.

3. Member is reimbursed by cheque or direct deposit once the dollar-amount or time-period threshold is reached.

Mark-up not allowed on the actual drug cost per

contractual agreement between pharmacies & Assure

◦ Be aware that for smaller community “Mom & Pop” pharmacies, the contractual agreement between a pharmacy & Assure may not be established.

◦ Where no contractual agreement is in-place, your drug cost will not be cut-back to a reasonable & customary charge. You will simply be reimbursed at 80% of the total drug card for eligible Rx drug claims.

Dispensing fees are not managed by Assure

Pharmacist can continue to charge whatever they want for dispensing fees so shop around!

Agreement established with Assure

NO agreement in place with Assure (ie: Mom & Pop shop)

Drug: Tylenol 3

R&C cost = $30.00

__________________________

$30.00 x 80% = $24.00

Out-of-pocket cost = $6

(so, your 20% that’s not covered = $6)

Drug: Tylenol 3 Cost (w/mark-up) = $35.00 __________________________ $35.00 x 80% = $28.00 Out-of-pocket cost = $7

(so, your 20% that’s not

covered = $7. In this sample, although you’re reimbursed at 80%, your out-of-pocket cost is higher)

When plan members are covered by more than one drug plan, benefits from both plans can be coordinated at the pharmacy counter when a prescription is filled for a patient. To take advantage of electronic coordination of benefits, plan members need to provide their drug card to the pharmacist. The pharmacist may then submit both the primary and secondary claim electronically at the point of sale. Once processed, plan members need only pay the remaining amount not covered by the various drug plans. This means minimal out-of-pocket expense for the patient at the pharmacy, while controls on claims reimbursement are exercised.

When a plan member presents their drug card at the pharmacy counter to electronically process their prescription claim, the employee's benefits can be coordinated with their spouse's drug insurance benefits according to the CLHIA (Canadian Life and Health Insurance Association) guidelines.

At the time of enrollment, each employee must declare if his/her spouse has other drug coverage with another insurer. This information is registered in the spouse's file to ensure that claims submitted to Assure for processing are processed as a second payor. All claims for spouses and children are validated electronically according to "first or second payor" status and are declined if not submitted properly.

If spouse doesn’t have a drug card (PDD or DDP), and

they are 1st payor, then a paper claim needs to be submitted for them.

Please note that the birth control (contraceptives) used for medical reasons only and the 4 DINS (listed below) used for Induced Gastric Ulcers only will have to be handled manually by Great-West Life; therefore, these drugs cannot be purchased using the drug card. Employees will have to pay first and use the ASSURE CARD CLAIM FORM to get reimbursed.

1. 2244022 - APO MISOPROSTOL

2. 2240754 - NOVO MISOPROSTOL

3. 2185466 - MISOPROSTOL

4. 813966 - CYTOTEC

There are times when pharmacists do not explain why a particular claim was rejected. Members might complain that their pharmacists simply say, "This card doesn't work!"

Many common reasons for a claim being rejected include: ◦ A dependant not registered (i.e. a new birth, new

spouse, etc.),

◦ Incorrect dependant code,

◦ The dependant is now above the age specified for coverage, and

◦ An incorrect date of birth has been submitted.

Rejection codes & their descriptions are available on the pharmacists database. It is the pharmacists responsibility to relay these “rejection messages” to the member. If a coverage problem occurs, the member must be directed to the local employer & the required paperwork is then sent to the Benefit Administration Office in order to register the new dependent, ensure the correct date of birth, or ensure the appropriate information concerning a full-time student dependant has been given to the benefits office. Once the updated information has been relayed to GWL, the files will be updated electronically. Please note that these reject messages will continue to occur until the time that the necessary member profile adjustments are applied.

Customers sometimes state that they have had to pay for ingredient price cutbacks. They believe the system unfairly penalizes them when the pharmacy and Assure don't agree on price and they are asked to pay the difference.

The price files at Assure are established from various reliable sources and allow a reasonable markup. Part of the agreement with Assure is that the pharmacy accepts their adjudicated ingredient cost payment and not charge the customer any excess amount.

If you have actually paid more for the drug than Assure allows, contact the Benefits Office with a copy of the most recent invoice you received for the product, by fax or by mail, referencing the claim that was affected. The Benefits Office, with GWL, will work on your behalf to ensure that your claim is re-assessed and adjudicated correctly.

Problem with claim?

◦ At time of purchase, the pharmacist must call Assure directly. They have their own phone number (Pharmacist line) with Assure to verify any claim submission problems.

Possible keying error on part of pharmacist.