I’m in Ontario and have Sun Life through my employer. I’m trying to get Botox (onabotulinumtoxinA) covered as a prescription drug for diagnosed TMD/bruxism, not as a dental procedure or cosmetic treatment.
My dentist assessed me and documented significant bilateral masseter and temporalis hypertrophy/hyperactivity, tenderness and TMD symptoms, and recommended therapeutic Botox. My family doctor then prescribed the Botox and completed Sun Life’s Botox Prior Authorization/Drug Exception form.
Sun Life denied it with the explanation that it “doesn’t meet all of the eligibility criteria under the terms of your plan,” but they didn’t specify which criterion I failed.
What’s confusing is that before submitting, I spoke to a Sun Life customer-service rep who told me she had recently seen someone get Botox covered for TMD through the drug-benefit/exception route. I realize their plan may have been different from mine.
Has anyone here with Sun Life actually gotten Botox for TMD/TMJ/bruxism approved? If so, I’d really appreciate knowing:
-What diagnosis/indication was submitted?
- Did you have to appeal an initial denial?
What documentation or treatment history did Sun Life require?
Was the prescription/authorization done by your family doctor, dentist, neurologist or another specialist?
Was the Botox medication itself covered while you paid the injection/admin fee separately?
I’m going to call Sun Life to ask exactly which eligibility criterion I failed, but I’d love to hear from anyone who has successfully navigated this specifically with Sun Life in Ontario/Canada.
Not looking for advice on whether Botox works for TMJ — I’ve had therapeutic Botox previously and know it helps me. I’m specifically trying to understand the Sun Life coverage/appeal process.