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Changes to specific diabetes management drug coverage

To: Donna Morrison, Executive Director

From: Eligible OSSTF Benefits plan members

June 1, 2023

Drug coverage for plan members and/or their eligible dependants with diabetes is an important and valued part of the OSSTF ELHT benefits plan. To ensure that the OSSTF ELHT plan can continue to provide sustainable benefits, commencing June 1, 2023, plan members and/or their eligible dependants who are newly prescribed diabetes management drugs will be required to demonstrate a prior claims history of diabetes management to be eligible for second line diabetic drug therapy reimbursement under the plan.

Effective June 1, 2023, the process will be:

  • For Diabetes Second Line Drug Therapy

New second line drugs may be approved for use in the treatment of type 2 diabetes only if plan members and/or eligible dependents have already tried a first line therapy. This is an automated Manulife process that will be enabled for all new claimants to assist with validating eligible diabetes drug claims, prior to approving coverage for higher cost second line therapy drugs. 

  • For Diabetes Semaglutide Drugs

Specific diabetes semaglutide drugs (Ozempic and Rybelsus) and Mounjaro (a tirzepalitide) will be moved to the FACET prior authorization program for all new claimants. Reimbursement for existing claimants on Ozempic and Rybelsus will continue to be paid; however, dosage changes may result in a referral to the FACET program. 

These administrative process changes have been made to safeguard the sustainability of the OSSTF ELHT benefits plan against off-label usage of these drugs. 

 

Questions? 

If you have any questions about these changes, please contact OTIP Benefits Services at 1-866-783-6847 to speak to a service representative. 


The information in this document is provided by OSSTF Benefits for general information only. OSSTF Benefits endeavours to have all information current and accurate. We make no representations or warranties of any kind, express or implied, about the completeness, accuracy, reliability, or suitability of the information included. All information is subject to change without notice.


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