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Ministry Status: Activation Status

OHIP+: Children and Youth Pharmacare

OHIP+ Stakeholder E–blast

Patients First

Update: OHIP+ Children and Youth Pharmacare Program

November 10, 2017

Colleagues,

We are pleased to share this update on OHIP+: Children and Youth Pharmacare (OHIP+) with you.

You can count on regular emails like this as your source of ongoing information and updates on OHIP+.  We encourage you to share them with staff members, local stakeholders and other clinicians, and colleagues.

Starting January 1, 2018, OHIP+ will cover all drugs and drug products currently reimbursed through the Ontario Drug Benefit program. This includes more than 4,400 drug products on the Ontario Drug Benefit Formulary. To check if a medication is covered by the formulary:

https://www.ontario.ca/page/check-medication-coverage/

It will also cover additional drugs through the Exceptional Access Program (EAP) under specific clinical circumstances. To access medications through the EAP, doctors or nurse practitioners have to submit a request to the ministry on the patient’s behalf.

Transition strategy - Exceptional Access Program

The Canadian Life and Health Insurance Association (CLHIA), its member insurance companies and the Ontario government want to help ensure that no one age 24 years and under with private insurance experiences a gap in coverage on January 1, 2018.  To this end, we have been working together to help ensure children and youth with private insurance coverage experience a smooth transition from private plans to OHIP+ beginning January 1, 2018.

Because drug funding decisions under the EAP can take time, from January 1 – June 30, 2018 private insurers are assisting with coverage for some drugs that may otherwise be considered under the EAP without an EAP rejection letter.

“The Canadian life and health insurance industry is pleased to collaborate with the Ontario government on this import initiative, in particular to help ensure that the transition from private plans to OHIP+ is as trouble-free and straightforward as possible” said Stephen Frank, President and CEO of the Canadian Life and Health Insurance Association.

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.

The kinds of EAP drugs insurance carriers will continue to consider from January 1 to June 30, 2018 without first requiring an EAP rejection fall into three categories:

  • Antibiotics (and anti-infectives, including antiviral and antifungal agents)
    • Many antibiotics/anti-infectives are covered on the Formulary. Some antibiotics are only accessible through the EAP.
    • Most are prescribed as a 7 or 14 day course of treatment, and any delay in accessing antibiotics to treat an acute illness may worsen a patient’s condition.
  • Blood thinners (low molecular weight heparins)
    • The Formulary contains a number of other blood thinners.
    • Blood thinners are often used before and after surgery to prevent or treat a blood clot. Any delay in accessing blood thinners in these circumstances may lead to other health issues.
  • Drugs with low Exceptional Access Program approval rates
  • There are a variety of drugs that the public drug plan does not usually approve for funding, except in very specific circumstances; the ministry and private insurers do not want to delay medical treatment while waiting for a funding decision.

Please note: For individuals accessing the above medications during the transition period, regular deductibles and co-payments will still apply under the patient’s private insurance plan.

Starting on July 1, 2018, private insurers will require patients to be assessed and denied funding through the EAP for the above noted drugs, before they will consider covering the drug through a private plan.

How to apply for EAP Coverage

For children/youth who require an EAP request, a new shorter EAP form has been developed for some commonly prescribed medications. This streamlined process will minimize EAP delays for patients who have been stabilized on a medication and require an EAP assessment prior to January 1, 2018.

Prescribers are encouraged to submit EAP requests for children/youth before January 1, 2018. EAP streamlined forms can be accessed at:

www.forms.ssb.gov.on.ca/

Form Number: 014-5067-87E

Title: OHIP+ Eligible Recipient Request for an Unlisted Drug - Exceptional Access Program

The EAP streamlined form can also be filled out electronically and then printed and faxed to 1-844-227-6590.

Prescribers can also select a drug from the form’s drop down menu and complete the form by hand. Once the form is completed, fax it to 1-844-227-6590.

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 send full OHIP+ EAP requests to the dedicated OHIP+ EAP fax number 1-844-227-6590 for children and youth seeking an assessment for January 1, 2018. Full EAP requests can be found at:

health.gov.on.ca/en/pro/programs/drugs/eap_mn.aspx#3

Webinars

We will be hosting weekly webinars to provide an overview of OHIP+ and the process to submit EAP requests, as well as to answer questions.  Webinars will be held each week on Thursdays from 12:00-1:00 pm.

Please join us for our next webinar on November 16, 2017 from 12:00-1:00 pm. Click on the link below to access the webinar.

https://ali.health.gov.on.ca/r3h4qpn4pb8/

More Updates Coming

You can expect regular updates like this as we move forward.

Please Stay in Touch

Visit us online at www.ontario.ca/OHIPplus

OHIP+: Information for Professionals: http://www.health.gov.on.ca/en/pro/programs/drugs/ohipplus/

To automatically receive these updates, join our mailing list by emailing OHIPplus@ontario.ca

This document is available in alternate formats upon request.


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