Starting January 1, 2018, more than 4,400 drug products will be free for anyone age 24 years or younger with a valid Health Card.
OHIP+ is a major change in the pharmacy profession. As such, OPA is committed to working with the MOHLTC to ensure OHIP+ is working well and it’s a smooth transition for both the pharmacy profession and the people they serve.
What to expect:
Pharmacies may experience higher volumes of prescriptions for younger patients during the initial stages of OHIP+ and will be required to provide additional information to patients or families about the program— specifically when adjudication reveals that the drug is not covered by the ODB formulary.
While it’s too soon to know how patients will be affected in this way, the ministry has taken the following measures to facilitate the process:
A streamlined process for certain medications. For children and youth already stabilized on drugs that will require EAP approval, a simpler EAP application form has been developed for prescribers. A fact sheet on the EAP, which includes a list of the drugs eligible for the streamlined process, is available online.
If a medication is not covered under the OHIP+ program, patients and families are encouraged to speak with prescribers about other treatments which may be covered. Alternatively, this product may be covered by a third party payor (e.g. private insurance).
Members are reminded that contacting the prescriber to change a medication to an eligible benefit is not considered a pharmaceutical opinion and is not eligible for reimbursement under the Pharmaceutical Opinion Program (POP). Recommendations that would be considered eligible for the POP include:
- Therapeutic duplication; drug may not be necessary
- Requires drug; needs additional drug therapy
- Sub-optimal response to a drug
- Dosage too low
- Adverse drug reaction
- Dangerously high dose; potential overuse; abuse
- Non-compliance / Adherence
- Confirmed forgery or falsified prescription
A grace period for three drug categories. While details are still to come, talks between the Ministry and the Canadian Life and Health Insurance Association (CLHIA) have resulted in a six-month transitional period (until June 30, 2018), during which time insurers that are members of CLHIA will be the first payer for certain drugs that are not on ODB’s formulary, without requiring proof that EAP coverage has been denied. This applies to drugs in three drug categories: antibiotics/anti-infectives, blood thinners and drugs known to have low EAP approval rates. Regular deductibles and co-payments required by private plans will continue to apply. It’s important to note, however, that individual insurers—or even individual drug plans—may shorten the length of the transitional period or not participate at all (particularly among smaller insurers that are not members of CLHIA).
This transition period will give physicians or nurse practitioners time to consider whether there are alternatives on the Formulary. It will also give them time to submit requests for drug funding on their patient’s behalf, without experiencing an interruption in drug coverage.
Prescribers are encouraged to familiarize themselves with the Formulary to ensure that where appropriate, Formulary products are prescribed, thereby reducing any potential delay in access to medications.
Tips to prepare:
- Start adding OHIP numbers to all files for all patients under 25 now.
- Start getting limited use (LU) codes from prescribers by having your pharmacy system run a report on all patients under 25 taking drugs that require a LU code (such as Advair), then contacting prescribers.
- Help ensure that all patients under 25 taking drugs that will require EAP assessment have submitted their application; send prescribers the full or streamlined EAP form.
- For students studying outside of Ontario, recommend travel supplies before heading back to school after the holidays since OHIP+ prescriptions must be filled in Ontario.
- If patients wish to stay on a brand-name drug that’s not the lowest-cost interchangeable drug (and hence not covered by ODB), advise them that their private plan may be able to pay the difference in cost and offer to contact their insurer to determine if this is the case.