What is OHIP+: Children and Youth Pharmacare?
Beginning January 1, 2018, the province will provide drug coverage for children and youth who are covered by OHIP and aged 24 and under, regardless of family income.
Enrollment in OHIP+ will be automatic based on age and eligible drug products will be available at no cost. There will be no applications necessary to join the program and no upfront costs to acquire eligible medications at the pharmacy. Those who are eligible for the program would only need to have their health card number and a valid prescription starting January 1, 2018.
Under this program, over four million Ontario children and youth will have publicly funded access to over 4,400 drug products.
1. What drugs and services will be covered?
The new OHIP+ program will cover all drugs and services currently covered through the Ontario Drug Benefit (ODB) program. This includes more than 4,400 drug products listed on the ODB Formulary/Comparative Drug Index and additional drugs eligible for funding through the Exceptional Access Program (EAP). If a drug product is not available through the ODB program it will not be covered through OHIP+.
Examples of common drug products and services that may be used by children and youth, age 24 and under, which are covered through the ODB program, include:
- Antibiotics to treat infections
- Inhalers for asthma
- Various insulins, oral diabetic medications and diabetes test strips
- Oral contraceptives
- Epilepsy drugs
- Medications to treat mental health conditions
- Attention deficit hyperactivity disorder (ADHD) drugs
- Some cancer drugs and drugs for rare diseases
- Pharmacy Smoking Cessation Program
The Ontario Drug Benefit Formulary/ Comparative Drug Index has a search function that can be accessed online .
2. How will Pharmacies be reimbursed?
Pharmacies will receive $8.83 or relative fees in rural areas for each eligible prescription dispensed plus the applicable mark-up. Professional pharmacy services such as the Pharmacy Smoking Cessation Program and the Pharmaceutical Opinion Program will be reimbursed in the same manner as is currently in place for existing Ontario Drug Benefit recipients.
Exceptional Access Program (EAP)
The EAP facilitates access to drugs not funded through the ODB Formulary, or where no listed alternative is available. In order to receive coverage, the child or youth must be eligible to receive benefits under the ODB program.
Under OHIP+: Children and Youth Pharmacare Program, children and youth will still need to have an application submitted by their primary prescriber for assessment through the EAP. Refer to question #9 for more information.
Children and youth that have an approved EAP request will be fully covered for the cost of their medications.
Additional information on Ontario’s Exceptional Access Program can be found at: https://www.ontario.ca/page/applying-exceptional-access-program
Trillium Drug Program (TDP)
Under the current regulation, there would be no change to the annual deductible amount as a result of the introduction of OHIP+. TDP households with members 24 and under would still have their incomes factored into deductible calculations, however, they would have no out of pocket expenses for individuals 24 and under to contribute toward meeting the TDP household deductible.
Individuals who are 24 years of age and are currently enrolled in the TDP will have OHIP+ coverage beginning January 1, 2018 until their 25th birthday. The Ontario Public Drug Programs will contact individuals prior to their 25th birthday to ensure that individuals that continue to need drug coverage are enrolled in the TDP.
3. If a child or youth is currently on a drug which is funded under a private insurance plan, will they continue to be covered for the drug under the new program?
If the drug is listed on the ODB Formulary coverage will be provided through OHIP+: Children and Youth Pharmacare Program.
If the drug is available through EAP, the child or youth must be assessed for coverage. Refer to Question 9-12 for more information.
If the drug is not currently funded through the ODB program it will not be funded through OHIP+: Children and Youth Pharmacare Program.
In the event that a currently prescribed medication is not an eligible benefit under OHIP+, patients/families should inquire with their primary prescriber regarding the appropriateness of switching to an alternate medication that would be covered through OHIP+ and the ODP program.
4. Can a patient opt out of the OHIP+ program?
All Ontario children and youth between the ages of 0 and 24 years of age with a valid health card number will automatically be enrolled in OHIP+. An individual who does not wish to receive coverage under the program can opt out of by contacting ServiceOntario INFOline at 1-866-532-3161.
5. If a patient is on Trillium(TDP) now, how would the pharmacy differentiate this patient vs. a non-Trillium OHIP+ patient?
If a patient is aged 24 and under, and they are OHIP insured, they will be eligible for ODB through OHIP+. The Ministry expectation is that a pharmacy would submit a claim with the Ontario Health Card Number for both OHIP+ and TDP beneficiaries. When the health card number is entered, HNS will select OHIP+ as the highest priority (if the beneficiary is also eligible for ODB benefits through any other eligibility stream, including through TDP); the claim response will indicate no co-payment or deductible.
6. Will the Trillium deductible for the family remain unchanged even though a family member is covered under a “different” ODB plan?
This is correct. The Trillium deductible for the family will remain unchanged. The TDP will continue to use the combined net income of all household members to calculate the annual deductible. However, TDP households will have no out-of-pocket drug expenses for children age 24 and under to contribute toward meeting the deductible.
7. If a patient is NOT eligible for a Limited Use code or EAP program, and ODB rejects accordingly, can we submit the claim to a Third Party Payor (TPP), if the patient has alternative coverage?
Claims for Limited Use (LU) drugs will be reimbursed under the Ontario Drug Benefit (ODB) program only when prescribed for an ODB-eligible recipient (including OHIP+ beneficiaries) in accordance with the criteria outlined for each product and accompanied by a valid, fully completed prescription with the appropriate LU documentation (RFU code). The pharmacist should review the prescription and process the claim only if all the required information is provided by the prescriber. HNS does not adjudicate LU criteria, so claims will not be rejected. Only a correct LU code for that drug will be required for HNS to accept the claim.
If the patient does not have an EAP approval, claims will be rejected by HNS.
At this time, the ministry is unable to confirm what the TPP will continue to cover as this will depend on the patient’s plan. The ministry is collaborating with the Canadian Life and Health Insurance Association (CLHIA) to ensure that there are no gaps in coverage for children and youth with the initiation of OHIP+. There will be no changes to how LU drugs are covered with OHIP+. If there is no LU code or the patient is not eligible for LU, then they can submit their request for coverage to a TPP to be assessed for coverage.
8. If there is a gap in communication with the MDs with respect to LUs and EAPs, and we do not have an LU or EAP in place, can we bill the third party payor without risk of an audit? (i.e. we may not have confirmation that the patient is not eligible, but given the timelines may not have an approval either).
ODB is the first payer for OHIP+ eligible recipients. Therefore, claims should be submitted to ODB first.
If an LU code is used or the patient is eligible for the LU, proper procedures should be followed and the patient should meet the clinical criteria. It is possible that this may be audited.
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.
Additionally, for the following three drug categories: antibiotics/anti-infectives, blood thinners and drugs known to have low EAP approval rates there will be 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. 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.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
9. How do patients apply for the Exceptional Access Program (EAP) using the Streamlined Request Submission Process?
Prescribers are able to submit a streamlined request for EAP for their patients, however it is important to note the following information about the OHIP+ EAP streamlined request submission process:
- It is only for OHIP+ eligible patients (i.e. Ontarians age 24 years and under) who have been stabilized on certain medications that require an EAP approval
- The form has been developed for the medications listed below only:
- Alcohol Addiction Therapy (acamprosate, naltrexone)
- Alfacalcidol (drops)
- Cortisone acetate (tablet)
- Dornase alfa
- Hormone Therapy (conjugated estrogen, estradiol, progesterone, testosterone)
- Iron dextran or iron sucrose
- Lamotrigine (chew)
- Lithium carbonate ER
- Metoclopramide (liquid)
- Multiple Sclerosis Therapy (Aubagio, Avonex, Betaseron, Copaxone, Extavia, Rebif, Tecfidera)
- Mycophenolate mofetil
- Phytonadione & Multivitamin (injections)
- Prochlorperazine (suppository)
- Sodium Bicarbonate
- Tranexamic acid
- Triptans (almotriptan, naratriptan, rizatriptan, sumatriptan)
- Vigabatrin (sachet)
EAP cannot be used for children and youth who are starting a new drug therapy after January 1, 2018 that requires an EAP assessment.
There are three ways for a prescriber to submit the OHIP+ EAP Streamlined Request Form:
- Fill it out electronically, and then print and fax it to 1-844-227-6590.
- Select a drug from the form’s drop down menu and complete the form by hand. Once the form is completed, fax the form to 1-844-227-6590.
- Mail it to Ontario Public Drug Programs at:
Ontario Public Drug Programs
Drug Programs Delivery Branch
3rd Floor, 5700 Yonge Street
Toronto, ON M2M 4K5
10. Is the Streamlined Request Submission Process for EAP eligible for all drugs?
No. Please refer to Question 10 for the list of eligible drugs for which a prescriber may use the streamlined request submission process. For drugs not available under the streamlined submission process, the ministry is encouraging prescribers to submit full EAP requests for OHIP+ eligible patients as soon as possible.
Please fax full EAP requests for OHIP+ eligible patients to 1-844-227-6590.
Note: This fax number is different than the fax number listed on the full EAP request form (which is used for regular EAP requests as well). Using this fax number will help expedite and prioritize your OHIP+ EAP request review.
Full Exceptional Access Program request forms and additional information on the EAP can be found online.
11. Is there a list available of all EAP eligible drugs?
The ministry continues to work closely with clinicians and other stakeholder groups to respond to feedback raised regarding OHIP+. Many clinicians have been requesting the EAP medication list. The ministry is pleased to provide the attached EAP list that represents drugs that have been considered for EAP funding recently to help guide the EAP request process.
If you are unable to find the information that you require regarding an EAP request, please contact Ontario Public Drug Programs:
Phone: 416-327-8109 or 1-866-811-9893
Fax: 416-327-7526 or 1-866-811-9908
12. Will Pharmacies be at a greater risk of audit now that it is up to each individual insurer/adjudicator to decide processes for coverage?
The MOHLTC is working closely with CLHIA to ensure that there is a smooth transition with OHIP+. However, as is the case today, it is up to each individual insurer to decide what drugs they will cover. Pharmacies should not be at risk if they are following the rules in their HNS agreement and the agreements with the TPPs.
13. Is the Limited Use criteria for covered medications effective immediately?
There is no change to the current process on how LU claims are adjudicated. OHIP+ eligible recipients will have coverage beginning January 1.
14. Does the ministry have a plan for a significantly higher Number of Rx’s requiring adjudication as of Jan 1?
The ministry’s I&IT team is working to ensure that OHIP+ will be ready on January 1 and all prescriptions (regardless of increased volumes) will be adjudicated.
The Ministry has an extensive testing strategy that includes performance testing to ensure that service levels are not impacted.
15. Will a help line be available on January 1, 2018?
The Ministry’s I&IT has been in discussions with the ODB Help Desk on an enhanced support strategy to ensure coverage over the holiday period. Staff will also be on site on December 31 and January 1 to support the implementation. You may also contact the ODB Pharmacy Help Desk at 1-800-668-6641 or email your questions to: PublicDrugPrgrms.email@example.com
16. Will this OHIP+ process delay coverage?
The ministry is preparing for increased volumes and is working closely with clinicians to explain the EAP process. In the interim, the ministry is working to ensure that there are no gaps in coverage.
17. Are prescribers allowed to charge a fee for Special Authorization Forms?
In accordance with the current Schedule of Benefits for physician services under the Health Insurance Act (HIA), completion of documents or transmitting information that would allow the patient to receive a benefit under a program administered by the Ministry of Health and Long-Term Care (MOHLTC) is included as a common element of an insured service. The ODB Program is administered by the MOHLTC. Under the Commitment to the Future of Medicare Act (CFMA), physicians cannot charge for an insured service rendered to an insured person.
Communications are being prepared that will be sent out prior to January 1, 2018 that will direct patients and prescribers to submit EAP requests or find suitable formulary alternatives if their private insurance does not cover the medication. The ministry is also working with private insurers to ensure that there are no gaps in coverage for children and youth.
18. How is the Dispensing of EpiPen® and EpiPen Jr® for Ontario Drug Benefit Recipients changing?
As of December 1, 2017, all ODB-eligible individuals, including those who will be eligible through OHIP+ starting January 1, 2018 (individuals aged 24 years and under with OHIP coverage), will no longer require a Special Authorization (Allergen) (SAA) form for an EpiPen® or EpiPen Jr® to be reimbursed through the Allergen program. A valid prescription will still be required, and billing procedures will remain the same.
It is important to note that valid and complete SAA forms will still be required for all other products dispensed by pharmacies and reimbursed through the Allergen program. SAA forms will also be required in order for non-pharmacy allergen extract suppliers to submit claims for payment to the Allergen program.
19. Will OHIP+ consider updating the formulary search to make it more user friendly?
The Ministry appreciates this feedback and is exploring opportunities to improve the public’s experience with our eFormulary. Any changes/developments will be shared/communicated with pharmacists, as available.
20. Under OHIP+ are patients required to have failed two generic interchangeable products with documented adverse reactions in order for a “no substitution” to be approved?
As OHIP+ will create a new eligibility stream under the ODB program, all OHIP+ recipients will be covered for the same drug products on the formulary as well as those eligible for funding through the EAP. In addition, all current ODB policies, pricing rules including generic interchangeability rules will apply. Pharmacists are required to dispense the lowest cost interchangeable product listed on the formulary to ODB recipients (this includes recipients eligible through OHIP+). Brand name drugs may be requested by the patient in place of the generic version if they are listed as interchangeable in the formulary, however, the patient would have to pay the difference in the cost, or it may be submitted to the private insurer who may cover the difference. Contact individual plan sponsors for details on whether they would cover the cost difference between the brand and generic.
In cases where a patient has experienced an adverse drug reaction when taking at least two of the interchangeable generic versions of a brand name drug (where available), the ODB program will cover the full cost of the brand name drug. In these cases, the doctor or nurse practitioner must write "no substitution" on each prescription and complete a Side Effect Reporting form to go with each prescription. The patient must take a copy of the completed Side Effect Reporting form, together with the "no substitution" prescription, to the pharmacist when filling the prescription.
21. What is the Temporary Facilitated Access Mechanism for Rheumatology?
Effective January 1, 2018, the Ontario Public Drug Programs (OPDP) will implement a Temporary Facilitated Access mechanism for rheumatology (TFA Rheumatology) that will provide coverage for certain biologics for select indications when prescribed by approved prescribers for their patients aged 24 years and under who are eligible to receive benefits under the Ontario Drug Benefit (ODB) program, without the need for an Exceptional Access Program (EAP) request.
The following drug products are eligible for access through TFA Rheumatology. Under this mechanism, approved TFA Rheumatology prescribers do not need to submit an application to Exceptional Access Program if the drug is being used to treat the specified indication and if the prescriber determines that the patient’s circumstances meet the EAP approval criteria.
Drugs Covered Under TFA Rheumatology
Polyarticular juvenile idiopathic arthritis (pJIA)
Actemra, Enbrel*, Humira**, Orencia, Remicade
Systemic juvenile idiopathic arthritis (sJIA)
Actemra, Kineret (disease onset must be before age of 16 even if patient is currently over 16 years of age)
Juvenile spondyloarthritis or enthesitis-related arthritis (JSpA/ERA)
Enbrel, Remicade (disease onset must be before age of 16 even if patient is currently over 16 years of age)
Uveitis/non-infectious ocular inflammatory disease (OID)
*Note that Enbrel will only be eligible through TFA Rheumatology for patients who were stabilized on etanercept for pJIA prior to December 21, 2017. Effective December 21, 2017, the biosimilar Erezli (etanercept) is funded on the ODB Formulary as a Limited Use (LU) product for pJIA.
**Humira for pJIA – patients under 10 years of age are to be funded by the manufacturer.
Authorized prescribers will only be permitted to use the TFA Rheumatology mechanism if the posted online EAP criteria are met for the indication specified, as further explained below (http://www.health.gov.on.ca/en/pro/programs/drugs/docs/frequently_requested_drugs.pdf).
- For patients currently stable on a biologic who require ongoing coverage, they must have met the initial criteria prior to starting the biologic and any renewal criteria must be met before the TFA Rheumatology mechanism can be used to provide ongoing coverage on or after January 1, 2018.
- For new patients starting on a biologic after January 1, 2018, the TFA Rheumatology mechanism can be used if the initial EAP approval criteria are met.
- The TFA Rheumatology mechanism can also be used for renewals for existing EAP patients as long as the applicable renewal criteria are met.
If the applicable EAP criteria are met, then the authorized prescriber’s prescribing of the therapy will be deemed to satisfy the requirements in section 16 of the Ontario Drug Benefit Act for an EAP approval. An approved EAP request will NOT be required. The TFA Rheumatology mechanism can be used from January 1st, 2018 until December 31st, 2018.
The authorized prescriber must be a physician identified on the TFA Rheumatology List of Authorized Prescribers maintained by the Ontario Rheumatology Association, which is responsible for determining prescriber eligibility. For more information on TFA Rheumatology prescriber eligibility, please contact the ORA at firstname.lastname@example.org.
Rheumatologists granted TFA are expected to:
1. Only use the TFA Rheumatology mechanism if prescribing a drug product used to treat the specified indication on this list for an ODB eligible recipient aged 24 years and under.
2. Ensure that new patients meet the posted initial criteria prior to starting the biologic. For patients currently stable on a biologic, ensure they met the initial criteria prior to starting the biologic and currently meet renewal criteria. In the case of renewals, any renewal criteria must be met. All criteria are posted online (http://www.health.gov.on.ca/en/pro/programs/drugs/docs/frequently_requested_drugs.pdf).
3. Write a prescription and ensure the following are included:
- the drug
- the indication
- the dose and frequency of administration (only the standard dosing regimen for the patient’s age and weight is allowed, as posted online for the specific indications or according to the product monograph)
- quantity to be dispensed and/or repeats
- The words “Temporary Facilitated Access” or “TFA”
- Their College of Physicians and Surgeons of Ontario (CPSO) Registration/License Number
4. Sign and date the prescription
A pharmacist is required to validate that the drug and prescriber are eligible under the TFA Rheumatology mechanism.
Note: If the patient currently has a prescription for a biologic eligible for the TFA Rheumatology mechanism on file, effective January 1, 2018, they can refill the prescription under the TFA Rheumatology mechanism if the prescription is from an authorized prescriber on the TFA Rheumatology List of Authorized Prescribers. If a patient has an existing EAP approval for the biologic, the duration of the existing approval will continue to be valid. Additionally, the same prescription may also be dispensed using the TFA Rheumatology mechanism.