Guest Blog: Ontario Patient Faces a Maze of Coverage

(Patient has advanced kidney cancer requiring sunitinib (Sutent), an oral chemo drug approved on the Ontario Formulary, but not fully funded for those under 65 in Ontario.)

My wife's benefits were slashed once again "unofficially" due to my Sutent costs. She was slashed to $3000 yearly which doesn't do much for the Sutent costs. I also have Trillium as a secondary coverage - for many years but never really ever used it. Last month’s Sutent cost left me with a payment over $1000 of which I submitted the receipt to Trillium. As for the EAP program it says 100% coverage that I qualified for Sutent.

I called in for refills this morning and was told no coverage at the pharmacy level but send in more receipts for things like blood thinners, blood pressure & pain management. I called Trillium since I felt I met the requirements they explained so far and now they want a letter from my wife's benefit's company saying we've used up the coverage. I sent a letter in the spring explaining the coverage reduction from them. They know I covered the balance of the latest Sutent prescription because the benefits only covered approximately $3000. None of this was good enough and they want another letter saying the same from Winnipeg and I also have to wait another 7 - 10 business days for coverage after I get this all done. They have all this already but of course nothing with the precise numbers on paper which they already know when it's put through at the pharmacy level. Now this is nothing more than red tape run around at best.

They cry constantly about hospital costs and un-needed visits, well where do they think I'll be going for higher cost care because of this. Unbelievable. And best of all it takes Trillium numerous weeks to months to cover the receipts is what I'm told even though I'm not a new client and have EAP approval for coverage.

Name withheld to protect the patient.


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