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Plan updates

On September 1, 2023, we will introduce some plan enhancements. We are also introducing new drug management initiatives via the FACET Drug Prior Authorization Program.

Plan enhancements – Effective September 1, 2023

You and your covered dependents will each receive more coverage for mental health services and major restorative dental services plus new coverage for anti-obesity medications starting September 1, 2023, as follows:


 

Current coverage

Improved coverage

Mental health services

·     Psychologist

·     Social worker

·     Psychotherapist

·     Registered family therapist

Maximum $1,500
per benefit year (combined)

Maximum $2,100
per benefit year (combined)

Major restorative services
(E.g., crowns, onlays, dentures, bridgework)

60%, to a maximum
of $2,500 per benefit year

65%, to a maximum
of $2,500 per benefit year

Coverage for anti-obesity medications

No coverage

Covered, subject to restrictions

(clinical controls managed via the FACET Drug Prior Authorization Program)

Prior authorization for semaglutide drugs (e.g., Ozempic®)


Background information

Drugs that treat obesity have evolved over the past few years – with a few of them receiving a lot of attention.

Semaglutide is approved by Health Canada under the brand name Ozempic® for the treatment of Diabetes; yet is being used off-label for weight management with increasing frequency in many benefit plans. The off-label use of Ozempic® for weight management has made headlines across North America. 

The ONE-T plan has seen a significant and rapid increase in Ozempic® claims over the past year.

Wegovy®, a newer therapy also containing semaglutide, has been approved by Health Canada specifically for the treatment of obesity and is anticipated to reach the market later this year.

What’s changing?

As we balance providing meaningful benefits while ensuring the long-term sustainability of the plan, we are introducing – effective immediately – a new prior authorization process for all new semaglutide users via the FACET Drug Prior Authorization Program. This will help ensure that coverage is limited to those at the highest risk of negative health outcomes and who will most benefit from this drug.  

Plan members who take Ozempic® to treat Diabetes or who already have an existing Ozempic® prescription for weight management will continue to be covered. The change will be put in place for new users of semaglutide only.

FACET will manage new patient claims for semaglutide against clinical criteria set by the health technology assessment agencies, such as the Canadian Agency for Drugs and Technologies in Health (CADTH). FACET will ensure continued Ozempic® coverage for patients with Diabetes, while appropriately managing coverage for patients who use it for
weight loss if they meet the following criteria:

·      Class III Obesity (BMI ≥ 40kg/m2), or

·      Class II Obesity (BMI 35 – 39.9kg/m2), plus one or more weight-related comorbidities such as high blood pressure, elevated cholesterol, or sleep apnea.

These clinical criteria could change moving forward as new evidence emerges.

Biosimilar switching


Background information

When the patent on a biologic drug (called an “originator drug”) expires, other companies can produce a biosimilar version – which is a highly similar drug in terms of quality, effectiveness, and safety, but at a lower cost.

Earlier this year, Ontario announced it would be following other provinces to adopt biosimilar coverage for Ontario Drug Benefit (ODB) recipients. ODB identified eight originator biologic drugs for biosimilar switching. 

What’s changing?

ONE-T will align with the ODB biosimilar switching initiative. To start, the ONE-T plan will only provide coverage for the biosimilar version(s) of the first five originator drugs. With very few exceptions, the originator drugs will no longer be covered.

Originator drugBiosimilar(s) that will be covered

Humira®

Idacio®

Enbrel®

Brenzys®
Copaxone®Glactect®
Teva-Glatiramer Acetate®

Remicade®
Renflexis®

Rituxan®
Riabni®
Ruxience®
Riximyo®
Truxima®

NovoRapid®
Lantus®
Humalog®
Coming in 2024 – see note below

If you are currently taking one of the five originator drugs that will be replaced by a biosimilar, you will receive a detailed letter in early August from Canada Life. Your letter will outline the process and next steps to switch to a biosimilar drug that is covered by the ONE-T benefits plan. There will be a six-month transition period so you can work with your physician to safely move to the biosimilar drug. We encourage you to start this process as soon as you receive your letter, as it can take some time to schedule appointments with your physician and to make this transition.

Want to learn more about biosimilar drugs? Review this FAQ, developed by the FACET Drug Prior Authorization Program.

Coming in 2024: Our provider, Canada Life, is currently working on system changes to reimburse up to the lowest cost alternative biosimilar for the following three originator insulin drugs:

– NovoRapid®

– Lantus®

– Humalog®

Once this change takes effect, if you are using one of these originator insulin drugs, you can:

·      Update your prescription to a biosimilar option (at the pharmacy or in consultation with your physician), or

·      Continue to take the originator version; however, the ONE-T benefits plan will only cover up to the cost of the lowest biosimilar option (the “lowest cost alternative”)

Canada Life expects system changes will be completed in early 2024. More to come – we will notify you in advance of the system updates going live.

If you have any questions about your benefits coverage, reach out to Canada Life. 

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