Sun Life

This topic is intended for Independent pharmacies only and is not applicable to Rexall pharmacies.

During a transition period that started in November 2022, some Sun Life plans will be moved from Assure to Express Scripts Canada. Sun Life plans with a Carrier ID of 16 and a specific Group ID will be impacted. The transition will occur in 2 phases.

Public Service Health Care Plans (PSHCP) are adjudicated with Carrier IDs of 12 using the SL Bill Code. These plans are not impacted by the transition.

Pharmacy adjudication for affected Sun Life plans will be processed through Express Scripts. The effective date varies by Group ID with the first phase occurring on November 1, 2022.

During this transition, changes will be made automatically in Propel Rx to the following:

Patient Folders with Affected AS/AY Bill Codes

Active AS/AY Bill Codes for applicable patients will be inactivated with an expiry date entered.

An EP Bill Code will be added to these Patient Folders with an effective date entered. The EP Bill Code will be ranked one above the inactive AS/AY Bill Code. All third party numbers will be carried over, except for the 2-digit issue number at the end of a Client ID.

 

Prescriptions with Affected AS/AY Bill Codes

When filling a prescription, the Bill Codes may or may not be updated automatically in Rx Detail depending on whether:

  • The prescription is new or a refill/reAuth

  • The setting for the Reset Billing Code on Refill preference in Pharmacy Preferences

There is no impact on cancelling prescriptions filled previously with the AS/AY Bill Code.

Bill Codes that are locked will be automatically unlocked if they contain the affected AS/AY Bill Codes.

Table 1. Effect on prescription filling due to the Sun Life to Express Scripts Canada transition.

Prescription Reset Billing Code on Refill Outcome
New On The Bill field in Rx Detail excludes AS/AY and includes EP.
Off
Refill/ReAuth On The Bill field in Rx Detail excludes AS/AY and includes EP.
Off The EP Bill Code does not automatically appear in Rx Detail. You must manually update the Bill field.

Custom Classes, Pricing Rules, and Third Party Waive Rules for Assure

Custom classes, Pricing Rules, and Third Party Waive Rules will not be updated. Your pharmacy should evaluate the Pricing Rules and Third Party Waive Rules for Assure and determine if any changes need to be made for Express Scripts Canada.

Changes made to the Pricing Rules and Third Party Waive Rules for Express Scripts Canada will affect all Express Scripts plans, not just the transitioning Sun Life plans.

To update Pricing Rules:

  1. Select More > Pricing.

  2. On the left hand side, locate Assure. Dropdown the Assure tree.

  3. Select the Assure row and review the Strategies tab on the right hand side. Repeat for all rows under Assure. Evaluate if the Fixed Rules and Variable Rules should be applied for ESI Canada. If yes, continue to step 4.

  4. Select the ESI Canada row. Dropdown the ESI Canada tree.

  5. If the Custom Class or Drug Category already exists under ESI Canada, highlight the row and update the Strategies tab. If the row does not exist under ESI Canada, select Add to add the row and update the Strategies tab.

  6. Select the applicable Assure row and select Delete if needed.

  7. Select Save.

To update Third Party Waive Rules:

  1. Select More > Pricing.

  2. On the left hand side, select Assure.

  3. On the right hand side, select the Waive Rules tab. Evaluate if the Waive Rules should be applied for ESI Canada. If yes, continue to step 4.

  4. On the left hand side, select ESI Canada.

  5. On the right hand side, select the Waive Rules tab.

  6. Select Add to add a Third Party Waive Rule for ESI Canada or modify an existing rule. Set the parameters so that it matches Assure.

  7. On the left hand side, select Assure again. Select the Waives Rules tab. Clear the Third Party Waives Rules if needed.

  8. Select Save.

Error Troubleshooting

New drug cards can be downloaded by patients, but it is possible they may provide old Telus/Assure cards. If you receive a claim rejection from an Assure or Express Scripts plan with a Carrier ID of 16, see Table 2 for troubleshooting.

Table 2. Possible error messages when submitting a claim to Assure or Express Scripts Canada.

Error Message Recommended Actions
E1: Host Processing Error Incorrect adjudicator/Erreur destinataire – Re-submit to/Resoumettre à Express Scripts (ESC/ESI) IIN #610068 Re-submit the claim using the EP Bill Code. Confirm the 2-digit issue number is not included in the Patient Folder Third Party tab.
E1: Host Processing Error Incorrect adjudicator/Erreur destinataire – Re-submit to/Resoumettre à TELUS (Assure) IIN #600526 Re-submit the claim using the AS/AY Bill Code. Confirm the 2-digit issue number is included in the Client ID in the Patient Folder Third Party tab.
A8 – No reversal made – Orig. claim missing A8 – Aucune annulation N’a ete faite – Dem originale manquante Confirm the correct third party numbers are entered for the AS/AY or EP plans in the Patient Folder Third Party tab. If still unsuccessful, attempt a trace reversal.

Questions?

For questions regarding the entry of patient information in Propel Rx, please contact PTS Customer Care.

For general questions on the change from Sun Life to Express Scripts Canada, please consult the communication from Express Scripts Canada or contact their call centre.

You can find the contact information for a third party by highlighting the third party in the Patient Folder Third Party tab and selecting the Help button.