444 replies to this topic

[Sandibeach]

Can you provide the contract info at the NJC. Or do we write into Sunlife? I'm certainly prepared to write in, if more pressure is what it takes. I have a letter from them (Sunlife) from 2 years ago, before the quebec IVF - please let me know whom I should contact and I will send a letter off immediately. Sorry, I have no contacts for RAMQ in Quebec. I'm not sure why they need to contact them, it's all on their website, the detailed regulations... seems like a delay tactic..they can't blame someone else on not moving forward. I hope this is good news! Thanks for the update!!

[brightmb]

This is the contact that responded to my inquiry:

D'thea Webster, ABC

PSHCP Administration Authority

Tel: 613 565-1762 x242

Fax: 613 565-2780

dwebster@pshcp.ca

And He/she received it from the following NJC Contact (via forwarded email):

Nicole.Pare@njc-cnm.gc.ca
Executive Committee
Public Service Health Care Plan Partners
Union-Management Relations Committee

[Jiliana2]

Just chiming in that I am employed by the Federal Gov't and have SunLife. I just got my calendar yesterday for IVF #2... in the hopes that we can get as lucky as we did with IVF #1. I haven't paid the fees yet, but that'll be forthcoming, that's for sure.

I was part of the Expert Panel in Ontario and interviewed for the Raising Expectations paper and recommendations. I've been battling with the government, as well as various other politicians, and agencies for coverage and I'm NOT giving up. I'm a tenacious B*tch when I wanna be! A federal politician knocked on my door awhile ago (I live in Ottawa) and asked if he could count on my vote. I picked up my 15-month old daughter, and brought her to the door. "Do you see this little girl?" "Yes," he replied. "Well," I launched in..."she's the product of almost 7 years of infertility, about 30 thousand dollars and countless tears and heartbreak. We want to go back for another child, but I really don't think I should have to put a second mortgage on my house to do that, do you?" Needless to say, he was taken aback. I gave him my name, the address to my infertility blog and told him that it's time to give Ontarians the coverage they deserve. I can SEE Quebec from my house; do I have to move there to have IVF covered? That's discriminatory.

All that said, who do I contact at SunLife to submit my receipts and a copy of any details I can find? Is there an address? Is the address in the post above the one I ought to use? And I know one of you ladies mentioned a letter that you got from SunLife that might be of assistance (Ladybug maybe?). I'm open to receiving any and all information so that I too can join the fight. Again, if enough of us make an issue of this, it's bound to receive attention. Given that Quebec now covers the IVF procedure, it ought to be covered for other provinces (including Ontario) or we're looking at a case of discrimination based on residency. Ah... the "have" provinces vs. the "have-nots"... isn't it fun?

Lending my voice to the fight. I'm more than willing to help!

[PurpleFlowers]

collieflower - I don't mind at all sharing my letter. I'll scan it and send it to you. I had everything organized in a binder but for some reason that's not in there so once I find it I'll send it along. I read it again and the last page outlines what Ontario considers necessary to cover and it says that we can't use another province's criteria. My problem is I think it's really unfair that because some politician thinks it's only necessary for blocked tubes the rest of us suffer since we live here. I'll be appealing their denial when it comes to it. We're getting ready for number 4 so I'll be submitting a claim to SunLife.

hi ladybug:

we are just starting this process and had some questions. we've just mailed in our referral form to the clinic and have not contacted sunlife at this point. we'd like to give our first shot at sunlife all the help we can. so can you send us the sunlife letters you are talking about? does sunlife cover ivf treatment options then (not blocked tubes) - a little confused by all the posts and were things stand as of right now? do you have a sample letter we could use to write to sunlife? we live in ON.

[Sandibeach]

I was on the phone with Sunlife yesterday for other reasons and I asked the rep what was up with the IVF coverage. She said it's still under review, but with the decision that Blue Cross will cover DND and RCMP members, she said the govt likes to keept the coverage the same - in her opinion based on her past experience, Sunlife should be also coming to the same conclusion and covering IVF. Anyways it sounds promising - she just didn't have any timelines, so here's to keeping our fingers crossed. On another note, the drugs are still covered but ever since the card system came into place - Sunlife will only reimburse the generic amount or if no generic exists, the amount the fed govt has determined, which is lower than most pharmacies... so I'm not sure how much pharmacies are "overcharging" according to the govt.

[s00n]

Sunlife has a clause (in my policy anyways, PSHCP) that states coverage will be matched for things covered by other provinces under the PSHCP.

To me this is where the coverage for IVF comes in, but on the phone the person I talked to barely knew what an injection was, let alone ART.

I guess it's letter writing time again - this should be covered equally.

Sunlife doesn't cover Quebec, the Province does, but Sunlife had a statement somewhere (I've added it as a file attachment HERE)

[s00n]

I got coverage (no pre approval needed) for Femara (Letrozole) both generic and non. In 2010.

HI Ladies, I have phsp with the FEDS as well....Does anyone know if there is a limit on IVF meds ? I just received my pshp cards and am doing my third FET ( I've done 4 fresh cycles as well) adn suprefact was not covered ? Everything else with the new pshp card has been thus far (bcp etc.) so I am wondering what the problem might be. ANyone ever inquire of there is a limit on the number of cycles for IVF drugs ?

Thanks
Stacy

Hi Stacy,

I phoned once and asked whether there was a limit and they said no - that as long as the drugs were included on their list of approved meds, they would be covered - no limits. They did say, however, that not all medications would necessarily be covered (I can't remember which ones - I had a list). You should call and ask about specific meds. My last cycle included Gonal, Cetrotide and Prometrium and all were covered, but I was never on Suprefact.

Stacy,

I just looked in my files and found my list of meds that I asked them about (this was a couple of years ago) and I have a note that Suprefact is NOT covered - my note says because it is not classified by them as a fertility med? All of the other ones I have listed are covered except Femara, which I have a note saying that prior authorization is required.

Hope this helps.

[Sandibeach]

s00n - I agree, but there's also a clause that states when a procedure starts being covered as a new thing with a province, Sunlife (Really the NJC) has the right to review it before deciding to reimburse the procedure - hence why it's under review right now... I thought it was automatic, but it's not. But still looks promising either way, all that matters.

[s00n]

s00n - I agree, but there's also a clause that states when a procedure starts being covered as a new thing with a province, Sunlife (Really the NJC) has the right to review it before deciding to reimburse the procedure - hence why it's under review right now... I thought it was automatic, but it's not. But still looks promising either way, all that matters.

Thanks for the clarification. It's better than nothing but certainly not a sure thing. However, I hope they DO cover it. That'd be awesome.



By the way to all the other hopefuls, don't bother calling on the phone, people, the person you'll get really does NOT know a thing about this - trust me. Send a letter.

[hazypeanut]

Just sent out our appeal today... the girl we spoke to at sunlife on the phone, told us the more appeals they get, the faster they are going to have to move and she said each decision will most likely be individual. But she was the first person we spoke to who had an understanding of IVF and was all for it to be covered.. so she said it could take a max of 6 weeks to hear back on a decision.

We really stressed we needed to know ASAP due to tax time, because we WILL be claiming everything we can for this.

[snowflake_888]

Just sent out our appeal today... the girl we spoke to at sunlife on the phone, told us the more appeals they get, the faster they are going to have to move and she said each decision will most likely be individual. But she was the first person we spoke to who had an understanding of IVF and was all for it to be covered.. so she said it could take a max of 6 weeks to hear back on a decision.

We really stressed we needed to know ASAP due to tax time, because we WILL be claiming everything we can for this.

Did you have to state formally why you were appealing etc. (based on the clause about non-insured services being covered if they were covered by at least one other province)? Is there a form for filing the appeal or did you just write a letter? Sorry for all the questions - I just got my claim back denied as well - just wondering how to go about appealing. Thanks!

[Sandibeach]

I'm confused, I thought the decision wasn't made yet...that is what I was told less than 2 weeks ago. So they are now denying the IVF expense? I agree, send an appeal, but this is very dissapointing news. I thought they were holding onto all the claims until a decision was made...especially since RCMP and DND members now have coverage, you would expect we would be treated in a similiar manner.

[hazypeanut]

Hubby just typed up his own letter for the appeal..again explaining to them that it is now covered in quebec blah blah...and explaining my fertility issues etc, also he put in the end that we need to know asap due to income tax time, and we need to know how to file. hopefully we get at least a fair response.

[hazypeanut]

Sandi we are DND and they r still not covering it for us.

[snowflake_888]

Thanks for the reply Hazy. I'll send in an appeal letter too.

Sandibeach - mine was rejected - flat out - just found out last week. From what I understand, they are not holding on to them. They're still rejecting them, so I think the best thing to do is to file an appeal and that way if/when they do decide to cover, your appeal is on file. Just my understanding though.

Jen

[Sandibeach]

hazypeanut - are you a public servant or member with blue cross? Sunlife confirmed to me that bluecross is covering it with pre=approval, but only for members (those wearing uniforms)

Snowflake - that really sucks! I'm so pissed!! It seams like a cope out, yes file an appeal. I haven't started my new cycle yet, so I don't have anything to submit!

As for income taxes, file them as if you don't get a refund and if you do get it, then you can file an ammendment and send them a cheque...that's what I would do..cause as it stands today, you did not get reimbursed. This way you can get your refund.

[hazypeanut]

ahhhh Sandi, ya hubby is DND and he has blue cross...im with sunlife..i see the difference now..I think thats what we will end up doing with our taxes.. or wait 6 weeks to find out.but i dont wanna have to wait for another "no" ugh.

[hazypeanut]

ahhhh Sandi, ya hubby is DND and he has blue cross...im with sunlife..i see the difference now..I think thats what we will end up doing with our taxes.. or wait 6 weeks to find out.but i dont wanna have to wait for another "no" ugh.

[sweetdreams]

I really hope they will decide to cover it.

[countingdown]

Hazypeanut - what exactly did your rejection letter say?

I also submitted my claim for my cycle in January. I got a claim statement back with 0 reimbursed but the statement said Note D98 "We will provide you with additional information shortly". I did not take this as a outright rejection - just that more information will come in time. I've received nothing more since that letter dated Feb. 9, 2011.

[hazypeanut]

Countingdown, we had the same answer in the beginning... D98, but then we got a letter saying that basically OHIP covers tubal blockage, which btw WE KNOW lol.. everyone going through IVF in ontario most likely already knows this. They kind of made it seem like we had no idea in the letter.. I mean the reason we r trying to have insurance cover this now, is because we can't get OHIP coverage.. and now because Quebec is covering, we are appealing their decision.

[countingdown]

Got my rejection letter today. Stupidist letter ever really. It says that it needs to be covered in at least one province to be covered by the PSCHP and that Ontario covers IVF for bilateral blocked tubes.

Here is my response:

I am writing this letter to appeal the rejection of my claim that I received on March 9, 2011.

I thank you for clearly outlining the circumstances in which I would be eligible for reimbursement of physician services. I assure you that I meet both criteria, which were outlined in your letter as follows:

1. If the services rendered by the physician are not eligible for reimbursement under your own provincial health insurance plan, and

2. If such services are eligible for reimbursement under at least one other provincial health insurance plan.

With respect to the first point, I am a resident of the province of Ontario. Your letter is correct in outlining that OHIP will only cover IVF when it is required due to bilateral blocked tubes. As you have determined, I was required to undertake IVF for other reasons and was thus not covered under OHIP. As a result, I clearly meet the first criteria that you outlined, in that the services that were required by a physician were not eligible for reimbursement under my own provincial health insurance.

With respect to the second point, IVF is eligible for funding, in circumstances other than the complete bilateral blocked tubes, in the Province of Quebec. The province of Quebec began publicly funding IVF for all causes of infertility beginning August 5, 2010. As a result, I also meet your second criteria in that at least one other provincial health insurance plan in Canada does cover IVF for the reasons that I required it. Please note that the province of Quebec also is also now publicly fundig ICSI when it is required.

As such, in light of this information, I am appealing the decision to reject my claim and requesting reimbursement for the IVF, for which I am entitled to in accordance with the PSCHP.

Sincerely,

[honeybee2]

I’m not getting anywhere with Sun Life. Back in August, before I started any IVF procedures, I sent a letter to the PSHCP Administration Authority asking if IVF would now be covered because Quebec is covering it. They replied that it was under review and they’d let members know about any major changes to coverage.

Then, I found out that my tubes are functionally blocked. I got a letter from my RE stating that I required IVF because my tubes don’t work, and I submitted that to Sun Life along with my receipt for my IVF cycle in November. I didn’t get a claim statement back until January. It said that “The eligibility of this product or service is currently under review. Once a decision is made, we will let you know whether this expense is eligible under your benefits plan.” (I also tried claiming DH’s sperm analysis fees as ‘lab fees’ but they denied that claim).

I called the PSHCP call centre to find out when the review might be completed. The first person I talked to said my claim was being reviewed, and they had 30 days to review it which would be up the following week. She said if I didn’t hear anything I should call back. I said I thought it should be approved based on my doctor’s letter, and she said they’d look into it.

I called back over a week later and this time I was told that my claim had originally been denied, but the whole coverage for IVF is under review. He also said that my claim had been sent for adjustment based on my last call. He said he would send a note to the adjustment department saying that I would like more information on the status of my claim and that I would be happy to provide any additional information if they needed it.

When I hadn’t heard anything after two weeks, I went to the Secure message system on the Sun Life website and sent a message asking about my claim and asking if there is a service standard for turn-around time because I expected an answer long before now. I got a reply saying they are ‘reviewing the claim status further’ and a letter will be sent to me shortly.

It’s been very frustrating because that first IVF cycle resulted in a BFN, and we would like to cycle again soon. It makes a huge difference to us financially whether we get that money back. I have an appointment with my RE next week to discuss our next steps, and I was really hoping to have an answer by then. I can’t see how they can deny the claim, because I know others have been covered for blocked tubes outside of Ontario. DH is pushing me to take this to my union…I’m not quite ready to take that step yet.

It seems like they’re doing things extremely slowly, hoping I’ll go away. That’s not going to happen though.

[Sandibeach]

This really burns me... good letter. Let us know the outcome.

I might add a point, that if you resided in another province such as Alberta where there is no IVF coverage would you not get coverage (reimbursement)? And that you are being discriminated because you live in Ontario where there is limited IVF coverage and you do NOT meet their criteria for OHIP coverage, therefore residents of Ontario who are not eligible for OHIP coverage have a disadvantage to the rest of Canadian residents.

Good luck!

[hazypeanut]

SO we just got our reply from our appeal to the PSHCP that we sent on Feb 22.... i'll post it, its not long.. What else were we expecting.. :S

"The issue of IVF and associated costs is currently under review. Claims cannot be adjudicated and appeals cannot be resolved until we have a decision on the eligibility. Once a decision has been made, your request will be presented to the appeals commitee for a decision. Until then, if you incur any costs, we cannot confirm whether all or any of the costs will be covered under the PSHCP."

"We apologize for any delay or inconvenience this may cause and thank you for your patience."

Bunch of crap.