Drug Plans & Formularies

In this section you will find information and tools you need to manage the drug plans you encounter in day-to-day practice.

Each plan will have its own provider agreement, and it is important that you and your team understand the elements of each agreement. This will help prevent some of the problems associated with audits. It may be helpful (when re-negotiating your contracts with private payors) to suggest clauses and/or phrasing which protect your interests. To help, OPA has created some templates which pharmacists may find useful:

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WSIB narcotic formulary

The Workplace Safety and Insurance Board (WSIB) approach to narcotic management involves a unique narcotic formulary for patients with new injuries or recurrences. 

  • all claims for patients with new injuries or recurrences will initially only be approved if the prescription is written for a short-acting narcotic.
  • after 12 weeks of continuous narcotic use, WSIB clinical staff will review the case regarding ongoing use.
  • during the initial 12-week period, prescriptions for long-acting narcotics will not be reimbursed (and pharmacy claims will be rejected).

This initiative excludes cases within the Serious Injury, Pre-1990, and Occupational Disease programs. 

WSIB Narcotic Formulary Q&A – January 2010
Overview of the WSIB Narcotic Formulary – January 2010


Off-formulary interchangeable products

Interchangeability now applies to drugs that are not on the Formulary (i.e., those which are covered by private plans). More information can be found on the Ministry of Health and Long-Term Care website:

http://www.health.gov.on.ca/en/pro/programs/drugs/odbf_mn.aspx

Facilitated access mechanism for palliative care drugs

The Ministry has a consolidated list of participating physicians under the Ontario Drug Benefit (ODB) Program’s facilitated access mechanism for palliative care drugs. Please use as follows:

  1. download all three files below. 
  2. examine files one and two to determine if a particular physician is a participant under this program. 
  3. examine file three to determine if this physician is still a participant of the program.
  4. if you are having difficulty determine if a particular physician is under the ODB Program’s facilitated access mechanism for palliative care drugs, please contact OPA:

(416) 411-0788 ext. 4225
Toll-free 1-877-341-0788
E-mail: info@opatoday.com  

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Exceptional access program

As a result of the current drug shortage of formulary listed methotrexate 25mg/mL injection 2mL vials, an interim solution to avoid treatment interruption for patients who are eligible to receive benefits through the Ontario Drug Benefit Program is available through the Ministry’s Exceptional Access Program (EAP).  Pharmacies will be able to notify the Ministry’s Exceptional Access Program (EAP) on a case-by-case basis to be granted access to reimbursement of 2 mL vials of methotrexate 25 mg/mL injection manufactured by Teva Canada Ltd. (DIN 02099705) or by Pfizer Canada Inc. (DIN 02182955).  The communication from the Ministry can be viewed here.

The Ministry has consulted with the Ontario Pharmacists Association and the Ontario Rheumatology Association on a streamlined method of notifying the EAP to be granted temporary approval of reimbursement of the alternative methotrexate products that are not listed on the ODB formulary. Pharmacists are asked to complete the form below and submit the information faxed directly to the Ministry’s dedicated fax line at 416-314-3857 or toll-free:1-844-829-6807 to facilitate the notification process.

Dowload the form.

Audits

Audits are a necessary part of doing business, and our goal is to ensure the audit experience is as positive as possible for our members. You can ensure good audit results by understanding and following the terms of the contract (i.e., the plan’s Provider Agreement). 

If you have questions about the audit process or any concerns about your audit, please contact us at  info@opatoday.com.

Links to third-party plan sites

Where available, members can access provider agreements, pharmacy user manuals, updates, and other resources by following the links to the appropriate drug plan’s website.

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