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OSSTF Benefits Plan now includes psychotherapy

We are pleased to announce that your OSSTF Benefits Plan now includes psychotherapy.

What is Psychotherapy?

Psychotherapy is a term that covers all talking therapies and the many associated approaches/methods. Psychotherapists are mental health professionals who use “talking therapy” or counselling to help people work through difficult issues, rather than medications or physical interventions. People generally see psychotherapists when their problems affect their day-to-day living.

What is the benefits coverage?

Psychotherapy will be added to your plan at 100% coverage up to $2,000 per Plan Year combined for services of a psychologist, marriage and family therapist, social worker and psychotherapist. All psychotherapists must be licensed and registered in the province of coverage and all claims are subject to reasonable and customary charges.

Additional questions? For more detailed information on this new benefit, please review your benefits booklet located in My Claims. If you have any questions about your benefits plan, or if a claim would be eligible for coverage, please contact OTIP Benefits Services at 1-866-783-6847.

Be informed when buying your custom-made orthotics

To ensure you get a suitable custom-made orthotic, it’s important to ask questions and keep yourself informed throughout the purchasing process.

Under the OSSTF Benefits Plan, your coverage for casted, customer-made orthotics is: up to a maximum of $750 per plan year (an approved diagnosis from either a physician or a podiatrist/chiropodist is required.) The plan year is September to August.

Who’s authorized to prescribe and complete an assessment?

Custom-made orthotics are prescribed by specific health-care professionals, which include physicians, podiatrists and chiropodists. They will diagnose whether or not an orthotic would be beneficial to your situation. The prescribers and providers are licensed and governed by either a provincial or national body, and are subject to standards of practice. This, along with each body’s Code of Ethics, helps ensure their accountability and your protection.

For all Canadian provinces, except Quebec*, podiatrists, chiropodists, pedorthists are recognized as foot care specialists.

After being prescribed an orthotic, you’ll need to visit one of the providers listed above for an assessment. A provider will guide you through an extensive evaluation to ensure an orthotic is the best option and that it’s properly designed. You should expect the orthotic provider to perform the following:

Medical history review: A complete investigation and documentation of your medical history, symptoms and previous injuries. The provider will also take into consideration your lifestyle (occupation and activities) as well as your current and past footwear (fit, style, wear and pattern).

Examination: A hands-on evaluation of the lower limbs including foot structure, alignment, strength, range of motion, soft-tissue damage as well as identifying any abnormalities.

Gait analysis: The provider will observe you walking to identify accommodations or abnormalities (e.g. whether you favour one leg or the other).

Orthotic evaluation: The provider will determine treatment options and explain how the treatments will address your specific needs.

Casting: A proper cast is essential to create a truly custom-made orthotic as it ensures that your orthotic is made with all of the contours and structure of your foot. Casting techniques include: foam box casting, plaster of paris slipper casting, contact digitizing and laser scanning.

Manufacturing: For an orthotic to be claimed under your benefits plan, it must be constructed from scratch and fabricated directly from your mould. You can expect at least one week between your initial assessment and your fitting appointments. Orthotics that are not manufactured specifically to your needs can result in pain by overstressing your muscles, bones and joints.

Dispensing: Custom-made orthotics should be fitted specifically for you and your footwear. The provider should evaluate how you walk while wearing the orthotics. You should also be offered a follow-up appointment within 2-6 weeks of receiving your orthotics.

Education: The provider should educate you on things like breaking in your new orthotics, lifespan, and how they should fit. You should also be made aware of any warning signs that the orthotics are not working properly and instructed to return if you experience any problems.

Here are some things to be cautious of when buying an orthotic:

  • For all Canadian provinces except Quebec*, prescribers and providers should have the following designations in their titles:
    • Physician – M.D.
    • Podiatrist – D.P.M.
    • Chiropodist – D. Ch. or D. Pod. M.
    • Pedorthist – C. Ped. (C). or C. Ped. (M.C.)
    • Orthotist – C.O. (C) or C.P.O. (C)
  • Under the OSSTF Benefits Plan, casted, custom-made orthotics must be recommended by a physician or podiatrist/chiropodist.
  • Question a provider who strongly recommends you see a doctor of his or her choosing for a referral instead of your family physician.
  • Question a provider who recommends your whole family could benefit from orthotics without having seen or assessed them individually.
  • Be suspicious of any provider that can’t answer your questions clearly or gives vague and ambiguous answers.
  • Having your footprint taken on an inkpad or using your shoe size to provide a prefabricated insole is not considered casting and does not qualify as custom-made.
  • Some providers will supply what’s called a “best fit” foot bed. These are prefabricated inserts that are matched to your cast; however, the cast is never used in the actual manufacturing of the orthotic. These are not considered custom-made and would not qualify under your benefit plan.
  • A provider should have the capacity to modify your orthotic.
  • Exercise caution when considering the purchase of orthotics from exhibits at trade shows, home shows or sportsman shows. If there’s a problem with the orthotic, returning it could be a problem, not to mention they probably aren’t custom-made. Exercise caution when considering the purchase from kiosks or booths in malls, department stores or over the internet for the same reasons.
  • Be wary of people who come to your home, or conduct group screenings of employees or family members without a proper evaluation.
  • “Two for the price of one” deals or “free giveaways” with your purchase are not allowed under the code of ethics that regulated providers and dispensers are bound by. Some providers will use these “freebies” to inflate the price of an orthotic.
  • Custom-made orthotics for children under five are highly uncommon. Skeletal or soft tissue injuries that require orthotic treatment don’t usually present themselves until a person is older. If for some reason they do need an orthotic, a medical doctor or pediatric specialist must prescribe it.
  • If you feel pressured to purchase additional products or are uncomfortable with the business practices of the provider, consider another provider.
  • Don’t ever give the provider a signed claim form.

Please note that some of the examples listed above may not pertain to your benefits plan. Consult your benefits booklet for details.

*For the province of Quebec a foot orthotist or an orthotist prosthetist working in a laboratory accredited by the Québec Ministry of Health and Social Services and who is a member of the Order of Professional Technologists of Quebec and a podiatrist are the eligible providers of orthotics.

Looking to get surgical stockings or compression stockings?

Did you know under the OSSTF Benefits Plan, your coverage for surgical stockings is: up to a maximum of six (6) pairs per plan year on a reasonable and customary basis? The plan year is September to August.

To avoid delays in processing your surgical stocking claims, please complete and sign the Extended Health Care Claim form and attach the following information:

From the physician/podiatrist:

  1. Diagnosis necessitating the surgical stockings (A medical referral is not a diagnosis and will be insufficient. A separate diagnosis in addition to the medical referral is required.)
  2. Description of what activities the surgical stockings will be primarily worn for (daily living, sports, etc.)
  3. Anticipated duration the surgical stockings will be required
  4. Verification if this is an initial purchase or reason for replacement

From the supplier:

  1. Itemized receipt including patient name, date of service and total amount of purchase
  2. Confirmation whether or not the surgical stockings are eligible for funding through a provincial plan (if “yes” and applicable, a copy of the provincial plan’s statement of payment is required)
  3. Make, model and style of the stockings (style: knee-high or full-length)
  4. Confirmation if the stockings are custom-made or off-the-shelf
  5. Gradient factor

Ensure all applicable sections of the claim form are completed and include copies of primary payment if coordination of benefits (COB) is required. Please send this information as instructed on the form.

NOTES:

  • It is strongly recommended a pre-determination be submitted prior to incurring expenses to ensure eligibility.
  • Any costs associated in obtaining the above information will be the responsibility of the patient. In some situations, we may request further information in order to confirm eligibility.

DID YOU KNOW?

If you have either lymphedema or a hypertrophic scar, you can apply for coverage with the Assistive Devices Program (ADP).

ADP’s allowance is 75% of the cost of:

  • Lymphedema compression stockings: 3 pairs over a 2-year period
  • Hypertrophic scar pressure stockings: 5 pairs over a 2-year period

NOTE: Varicose veins, diabetes, thromboses are not eligible under the ADP.

To apply to the ADP, please work with your service provider. If the ADP does not cover the full cost of your expense, you can submit the remainder to OSSTF Benefits Plan via My Claims or completing the Extended Health Benefit Claim form (PDF).

Questions about the ADP? You can learn more at: Garments, pumps and braces.

New Hire Communication

Boards and School Authorities have been provided with a OSSTF New Hire Letter (PDF) and the OSSTF 2018-19 Benefits at a glance (PDF) that they are encouraged to pass on to new hires. New members are encouraged to access these documents for their enrolment questions, or to call OTIP Benefits Services at 1-877-783-6847 if they do not receive their enrolment invite or if they need assistance in the enrolment process.

Are generics just as good as the brand-name drugs?

Myth: Brand-name drugs are safer and more effective than generic drugs.

Fact: Generic drugs are every bit as safe and effective as brand-name drugs. In fact, they are equivalent to the brand version in dosage, safety, strength, quality, the way they work and the way they’re taken.

 

Brand-name and generic drugs have one important thing in common: they’re designed to heal us or make us feel better. And one of the big differences between these drugs is the cost. To help manage drug costs while ensuring you and your family have access to appropriate drug therapy, your benefits plan includes mandatory generic substitution.

What is a generic drug?

Generics are similar, not identical, to brand-name drugs.

When a new drug is developed, found to be safe and effective, and finally approved, it’s usually patented. The patent protects the new drug from being copied for a period of 20 years. The new drug is marketed and sold only by the pharmaceutical company that developed it. When the patent-protected period ends, other companies can produce and sell the same drug as generic equivalents. Because the brand-name drug has already been proven, companies can save research and development costs and afford to charge less for the generic drug.

There may be many generic versions of the brand-name drug. Next time you are prescribed a drug by your doctor or visit your pharmacist to fill a prescription, consider asking the following questions:

  • Is this prescription for a generic drug?
  • Is there a generic version of my drug available?
  • Can I substitute my drug with the generic version?
  • How much will I save under my plan if I switch to a generic drug?

Win-win situation: Your plan and generic drugs

With mandatory generic substitution in your drug plan, any prescribed drug cost cannot be more than the price of the lower cost alternative drug (generic drug).

  • If you are prescribed a brand-name drug, and there is no generic or interchangeable drug, your plan will reimburse you the cost of the brand-name drug.
  • If there is a generic drug and you choose to buy the brand-name drug, your plan will reimburse you the cost of the generic drug only.

In some instances, you may experience an adverse reaction to the generic drug, or it is therapeutically ineffective. When this happens, medical evidence can be submitted to support why the brand-name drug is being prescribed. To get approved for a brand-name drug, you need to complete the Request for Approval of Brand-Name Drug form (www.otip.com/forms), have it signed by your doctor and return it to the address on the form. If approved, you will be paid back the cost of the brand-name drug.

Check your benefits booklet to learn more about your drug coverage or call OTIP Benefits Services at 1- 866-783-6847.

 

Sources:

http://www.choosinggenerics.ca

The Safety and Effectives of Generic Drugs, Government of Canada, https://www.canada.ca/en/healthcanada/services/healthy-living/your-health/medical-information/safety-effectiveness-generic-drugs.html, 2012

What is mandatory generic substitution?

To help manage the costs associated with prescription drugs, the OSSTF Benefits Plan includes mandatory generic substitution.

With a mandatory generic drug plan, any prescribed drug cost cannot exceed the price of the lower cost alternative drug, which is typically a “generic” drug.

  • If the drug you are prescribed is a “brand-name drug,” and there is no generic or interchangeable drug, your plan will reimburse you the cost* of the brand-name drug.
  • If there is a generic drug and you choose to buy the brand-name drug, your plan will reimburse you the cost* of the generic drug only.
  • In some instances, you may experience an adverse reaction to the generic drug, or it is therapeutically ineffective. When this happens, medical evidence can be submitted to support why the brand-name drug is being prescribed. To get approved for a brand-name drug, you need to complete the Request for Approval of Brand-Name Drug form (www.otip.com/forms), have it signed by your doctor and return it to the address on the form. If approved, you will be paid back the cost* of the brand-name drug.

*Reasonable and customary will be applied to the eligible amount

Here’s an example1 of how mandatory generic substitution works:

Brand-name Generic
Drug Name: Crestor   Apo-Rosuvastatin
DIN: 002247162   02337983
Strength: 10 mg   10 mg
Quantity: 90 tablets   90 tablets
Cost of the drug: $161.82   $24.60
Your plan covers: $24.60   $24.60
You Pay2: $137.22   $0.00

1Examples and pricing are based on the Ontario
market and provided by My drug plan tool. Prices
are estimates only, regional differences may vary,
and include some drug mark-ups. If you are
eligible for a dispensing fee, it will be included in
the drug cost shown in My drug plan.

2As per your benefits plan, you are reimbursed for
the lowest cost alternative (generic drug).

When filling a prescription – speak up!

In many provinces, pharmacists will automatically dispense the generic alternative as part of their standard practice unless the prescribing doctor has indicated that “no substitutions” should be made. If your doctor has indicated “no substitution,” you can ask your pharmacist to dispense the generic drug – or you can accept the brand-name drug, and pay the price difference between the brand-name and the generic drugs.

If you share in either the cost of your plan or the cost of your prescription, switching to generics may help you and your plan save some money!

Use My drug plan to look for generic drug options

My drug plan is a user-friendly, drug lookup tool (found in My Claims quick links). It can help you to manage your drug costs especially because you have a mandatory generic drug plan. You can find out if a generic drug is available or if prior authorization is needed. A drug library is also right at your fingertips.

IMPORTANT NOTES:

  • Drug costs seen in My drug plan are estimates only.
  • With a mandatory generic drug plan, any prescribed drug cost cannot exceed the price of the lower cost
    alternative drug, which is typically a “generic” drug.

    • If the drug you are prescribed is a “brand-name drug,” and there is no generic or interchangeable drug, your plan will reimburse* you the cost of the brand-name drug.
    • If there is a generic drug and you choose to buy the brand-name drug, your plan will reimburse* you the cost of the generic drug.

In some instances, you may experience an adverse reaction to the generic drug, or it is therapeutically ineffective. When this happens, medical evidence can be submitted to support why the brand-name drug is being prescribed. To get approved for a brand-name drug, you need to complete the Request for Approval of Brand-Name Drug form, have it signed by your doctor and return it to the address on the form. If approved, you will be paid back* the cost of the brand-name drug.

*Before you get any money back, reasonable and customary limitations, coinsurance\reimbursement, deductibles and/or maximums apply as per the terms and conditions in each plan (refer to your benefits booklet).

Are you eligible for the Prior Authorization Program?

Your benefits plan is designed to provide you and your family with financial protection for a variety of medical expenses, including prescription drugs. The Prior Authorization Program helps to manage drug costs while continuing to provide you with access to appropriate drug therapy. The program validates that the drug is prescribed for its intended use and meets the terms and conditions outlined in your benefits booklet.

For a specific list of drugs, additional medical information is needed before determining if the drug is eligible. A drug may be prescribed to treat different medical conditions; one condition that may be covered under your benefits plan and one that may not be.

NOTE: The list of drugs requiring prior authorization is updated regularly, so be sure to check it each time you receive a new prescription.

Here are some helpful hints to keep in mind the next time you visit your doctor or pharmacist or prescribed a drug:

When your doctor prescribes a new drug:
  • Tell them that prior authorization may be required for certain drugs.
  • Access My drug plan to determine if the new drug is available as a generic and/or requires prior authorization.
  • Share the list of drugs requiring prior authorization (found in My drug plan on My Claims).
  • Tell them about the other drugs that you are currently taking to discuss if there may be any adverse reaction or side-effects when taking them together.
  • Make them aware of any drug allergies or reactions you’ve experienced in the past.
  • If the drug requires prior authorization, email the Drug Prior Authorization form to your doctor to complete the appropriate sections of the form. Then, you complete the rest of the form and print and send it to the address on the form or use the Send documents function on the My Claims home page.
When you pick up your prescription from the pharmacist:
  • Make sure you understand the instructions on how to take your
    medication.
  • Ask about possible side-effects and what to do if you experience them.
Other consideration
  • Wear a medical ID bracelet or necklace, if you have a medical condition and/or a drug allergy.

Use My drug plan to look for generic drug options

My drug plan is a user-friendly, drug lookup tool (found in My Claims quick links). It can help you to manage your drug costs especially because you have a mandatory generic drug plan. You can find out if a generic drug is available or if prior authorization is needed. A drug library is also right at your fingertips

IMPORTANT NOTES:

  • Drug costs seen in My drug plan are estimates only.
  • With a mandatory generic drug plan, any prescribed drug cost cannot exceed the price of the lower cost alternative drug, which is typically a “generic” drug.
    • If the drug you are prescribed is a “brand-name drug,” and there is no generic or interchangeable drug, your plan will reimburse you the cost of the brand name drug.
    • If there is a generic drug and you choose to buy the brand-name drug, your plan will reimburse you the cost of the generic drug.
    • In some instances, you may experience an adverse reaction to the generic drug, or it is therapeutically ineffective. When this happens, medical evidence can be submitted to support why the brand-name drug is being prescribed. To get approved for a brandname drug, you need to complete the Request for Approval of Brand-Name Drug form, have it signed by your doctor and return it to the address on the form. If approved, you will be paid back the cost of the brand-name drug.

Help protect your benefits

As we approach the end of the year, please be mindful of some service providers’ marketing campaign to ‘use it or lose it’. These campaigns are designed to serve the providers who promote them, however using benefits that are not medically necessary does not serve to protect the overall health of your plan.

Benefits like massage therapy and orthotics have balances that reset every benefit year to ensure proper care as necessary for plan members and their families. However, if it is not medically necessary, maximizing all of your benefits will negatively impact the long-term sustainability of the benefits plan, and may affect everyone’s ability to access necessary benefits in the future. Therefore, your responsible use of the plan is in the best interests of yourself, your family and fellow plan members.

Did you know?

You can now check to see what specific brands and models of orthopaedic shoes may be covered by your OSSTF Benefits Plan. To see this list, log in to My Claims.

Before you purchase orthopaedic shoes:

  • Review your benefits booklet for plan details (check under Non-Dental Prostheses, Supports and Hearing Aids) and find out if you qualify.
  • Check the list to find out if your shoes are covered or not.
  • Submit an estimate to OTIP to see if your shoes will be paid for and that you have all the supporting documents.
  • Learn more about what is needed to submit an estimate or a claim for orthopaedic shoes.

Important notes:

  • Recommendation of either a physician or a podiatrist is required for stock-item orthopaedic shoes and modifications/adjustments to stock-item orthopaedic shoes.
  • All other coverage and eligibility requirements apply.
  • The list is subject to change without notice.

The list is available in English only.

Co-ordination of benefits

In families with two working adults, it is common to have access to more than one health plan. There may be some overlap in the types of benefits and/or services they cover.

Co-ordination of benefits is how insurance companies co-ordinate benefits and claim payments when you have coverage under more than one group health plan. This procedure, set out by the Canadian Life and Health Insurance Association (CLHIA), establishes which plan pays first and how benefits are calculated when a person makes a claim to more than one group plan, either as a member or as a dependant (spouse or child).

How does co-ordination of benefits help you and your plan?

By co-ordinating your plans together:

  • You can get up to 100% of your money back on your health and dental costs.
  • Your plan can share the expense with the other insurance plan which will have a positive impact on the long-term sustainability of the OSSTF Benefits Plan.

Ready to co-ordinate your benefits plans?

For more information on co-ordination of benefits, you can check out: