As plan sponsors wait for more information on changes to Ontario’s Trillium program for catastrophic drug costs, the Ontario Ministry of Health and Long-Term Care has signalled they won’t be happening by September as previously believed.
Early this year, the ministry informally announced it would automate the current paper-based system as of this fall. The move sparked widespread speculation among industry stakeholders as to whether the automation was merely an effort to simplify the process for beneficiaries so they no longer have to collect and submit paper receipts as records of their out-of-pocket expenses for drugs or if the changes would extend to co-ordination of benefits with private drug plans.
In a written statement to Benefits Canada, the ministry confirmed it “has been consulting with various stakeholders” and is “specifically looking at system changes that would enable the automatic co-ordination of benefits between Trillium and private insurance providers.”
Read: A primer on some of Canada’s catastrophic drug programs
The statement gave no indication of timing but it did refer to Ontario’s new pharmacare program for children and youth as a source of “further learning” about the co-ordination of benefits between public and private plans. The youth pharmacare program is to be in place in January 2018.
Karen Voin, assistant vice-president of group benefits and anti-fraud for the Canadian Life and Health Insurance Association, confirms that the association has been part of discussions with the ministry. “The hope is that [the process] would be similar to other jurisdictions, where there is a systematic approach to facilitate co-ordination. . . . However, no final decisions have been made,” she says.
While such automated co-ordination would benefit private plans, the program itself isn’t changing. In other words, Trillium will still use out-of-pocket expenses to determine eligibility, unlike other provincial programs that rely on total drug costs, regardless of who pays. With a deductible of roughly four per cent of net household income that, in Ontario, averages between $50,000 and $60,000, that translates into at least $2,000 in out-of-pocket expenses for the average household. The percentage of private drug plan members who currently pay that much is likely small, especially after accounting for co-ordination of benefits and other forms of financial assistance, such as pharmaceutical manufacturers’ patient support programs for high-cost drugs.
Read: Ontario pharmacare program provides some relief to plan sponsors
Editor’s note: Story updated June 28 to correct the deductible calculation according to net, rather than gross, income for the average household.