Drug Plans and Pricing

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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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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Third party contact guide for new pharmacies

OPA has compiled a list of third party payors to assist new pharmaices in the registration as providers.

Third party payor

Support line

New provider set up

ClaimSecure Inc.

1-888-513-4464

Hours of operation:
Monday to Friday 7 a.m. - 11 p.m.
Weekends 11 a.m. - 4 p.m.

Click here to access pharmacy provider agreement

Esorse

1-877-637-6773

Hours of operation:
Monday to Friday 8:45 a.m. - 6:15 p.m.

Click here to access pharmacy provider agreement

Express Scripts Canada

1-800-563-3274

Hours of operation:
Monday to Friday 6:30 a.m. - 12 midnight
Weekends and statutory holidays 8 a.m. - 12 midnight

Click here to access pharmacy provider agreement

Express Scripts Canada - NIHB

1-888-511-4666

Hours of operation:
Monday to Friday
6:30 a.m. - 8:30 p.m.

Click here to access pharmacy provider agreement

Green Shield Canada

1-888-711-1119

Hours of operation:
Monday to Friday 8:30 a.m. - 8:30 p.m.

Click here to access pharmacy provider agreement

Johnson Inc.

1-866-773-5467

Hours of operation:
Monday - Friday
8:30 a.m. - 8 p.m.

Click here to access pharmacy provider agreement

MDM Insurance Services Inc.

1-800-838-1531

Hours of operation:
Monday to Friday 8 a.m. - 5 p.m.

Click here to access pharmacy provider agreement

Medavie Blue Cross - General Line

1800-355-9133

Hours of operation:
Monday to Friday
8 a.m. - 8 p.m.

Click here to access pharmacy provider agreement

Canadian Armed Forces (CAF)
Royal Canadian Mounted Police (RCMP)*
Veterans Affairs Canada (VAC)

1-888-614-1880

Hours of operation:
7:30 a.m. - 6 p.m.

Click here to access pharmacy provider agreement

Immigration, Refugees and Citizenship Canada (IRCC) programs

1-888-614-1880

Hours of operation:
8:30 a.m. - 4:30 p.m.

Click here to access pharmacy provider agreement

NexgenRx

1-866-394-3648

Hours of operation:
Monday to Friday 8:30 a.m. - 10 p.m.

Click here to access pharmacy provider agreement

Ontario Drug Benefit

1-800-668-6641

Hours of operation:
Monday to Friday 8:30 a.m. - 5 p.m.

Contact ODB Help Desk for new provider registration:
1-800-668-6641

SES Benefits

1-888-939-8887

Hours of operation:
Monday to Friday 8 a.m. - 5 p.m.

Contact for new provider registration:
1-888-939-8885

Telus Health Solutions

Public Service Health Care Plan (PSHCP)

1-800-668-1608

Hours of operation:
Monday to Sunday 5:30 a.m. - 2 a.m.

Contact for new provider registration:
1-888-939-8885

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. 

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. Pharmacies have been provided this list vis the Ministry's ONEMail system. For questions on how to find this information, please contact the ODB Help Desk.

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.

Download the form.

Drug pricing

The Ontario Pharmacists Association has received many calls and emails from pharmacists and technicians regarding price inaccuracies and discrepancies between what is available from the supplier (manufacturer or wholesaler) and what is reimbursed by payors.

We have developed a simple tracking form to help us determine the sources of these problems (payor, supplier, or software provider) and resolve them as quickly as possible. Your contributions of data up to this point have been helpful. Please continue to submit examples of drug price errors for both public and private claims to OPA as soon as they are discovered to help us continue advocating on your behalf with the Ministry. We ask pharmacists and technicians to confirm with your store owner/manager the best process to submit data in order to eliminate duplication within your own pharmacy. Note that no provider of information is being collected or shared, and all submitted data on drug pricing will be collated and addresse din aggregate form.

Drug Price Inaccuracy Tracking Form (download, complete and email to info@opatoday.com or fax to 416-441-0791.

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