Wednesday, April 02, 2025
AMAPCEO has successfully reached an agreement with the Ontario Public Service (OPS) Employer that will require Canada Life to reimburse members’ claims for Ozempic if they were prescribed the drug before April 1, 2023.
The 2022–2025 OPS Collective Agreement established a “prior authorization program” as part of members’ drug coverage. Under this program, Canada Life administers a list of prescription drugs which require prior authorization from the insurer before they will be approved for coverage.
The Collective Agreement included a “grandparent clause” which established that members who were prescribed a drug before April 1, 2023 (the implementation date of the Collective Agreement) would not be subject to the prior authorization process, even if that drug is on the prior authorization list.
However, members began alerting AMAPCEO that Canada Life was not abiding by the grandparent clause and that their claims for the drug Ozempic were being denied or they were being asked to submit a prior authorization request, despite having been prescribed Ozempic before April 1, 2023.
AMAPCEO filed individual claims at the Joint Benefits Review Committee, and an Association Dispute on behalf of all members who may have been impacted by Canada Life’s actions. When these appeals and the dispute were not swiftly addressed, AMAPCEO pursued these claims to the Grievance Settlement Board. In a recent Memorandum of Settlement, the OPS Employer has agreed to instruct Canada Life to abide by the grandparent clause and reimburse members’ claims for Ozempic.
Going forward
If you are an AMAPCEO member who was on any OPS benefits plan and you were prescribed Ozempic prior to April 1, 2023, you should resubmit denied Ozempic claims to Canada Life for reimbursement.
If you were asked to submit a prior authorization form and declined, choosing to pay out of pocket instead, you can submit your claim for reimbursement now.
If you chose to use an alternate drug but would prefer to use Ozempic can now go back on Ozempic and feel confident that your claim will be approved.
Members may be requested to provide evidence they were taking Ozempic prior to April 1, 2023, and that any claims were not reimbursed by another insurance provider.
This Memorandum of Settlement applies specifically to Ozempic, but AMAPCEO strongly encourages members who are experiencing the same issue with a different drug on the Canada Life prior authorization list to contact an AMAPCEO Workplace Representative immediately. If you have had a claim denied or have been asked to submit a prior authorization request for a specific drug, despite being prescribed this drug before April 1, 2023, reach out to AMAPCEO right away.