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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 23, 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.

Transition strategy - Exceptional Access Program (EAP)

As announced in our e-blast on November 10, 2017, 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 and 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 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:

  1. Antibiotics (and anti-infectives, including antiviral and antifungal agents)
  2. Blood thinners (low molecular weight heparins)
  3. Drugs with low Exceptional Access Program approval rates

Please note, starting on July 1, 2018, private insurers will require patients to be assessed and denied funding through the EAP before they will consider covering the drug. 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.

Drugs with low Exceptional Access Program Approval Rates

We understand that following our announcement on November 10, there have been questions from clinicians seeking clarity regarding the types of drugs with low EAP approval rates. Examples of drugs with low EAP approval rates as noted in category three above include:

Generic Name or Category

Examples of Product Names

ALLERGY MEDICATIONS (HYDROXYZINE HCL, LORATADINE, TRIAMCINOLONE ACETONIDE)

Atarax, Claritin, Nasacort AQ

BENZYDAMINE HCL

Pharixia

GLYCOPYRROLATE

Glycopyrrolate Inj 0.2mg/mL

HYOSCINE BUTYLBROMIDE

Buscopan

LEUKOTRIENE RECEPTOR ANTAGONISTS (MONTELUKAST SODIUM, ZAFIRLUKAST)

Singulair 5mg, 10mg, Accolate

MIDAZOLAM

Midazolam Inj 5mg/mL

OMEPRAZOLE

Losec DR 10mg

SAPROPTERIN DIHYDROCHLORIDE

Kuvan

TRANSDERMAL HORMONE THERAPY (ETHINYL ESTRADIOL & NORELGESTROMIN, ESTRADIOL 17-B, NORETHINDRONE ACETATE & ESTRADIOL-17B)

Evra, Estrogel, Estradot, Estraderm, Estalis

ZOLMITRIPTAN

Zomig

Please note: The above list represents some of the more common drugs with low EAP approval rates that have been identified through private insurance claims for children/youth in the past year.  Some of these drugs or different strengths/formulations of the above are also available on the ODB formulary (some as Limited Use).

Children/youth and their families should speak with prescribers prior to January 1, 2018 regarding medications that may require an EAP request. Prescribers can submit EAP requests for eligible patients as soon as possible.

Please fax full EAP requests to 1-844-227-6590.

Full EAP request forms and additional information regarding Ontario’s EAP can be found at: health.gov.on.ca/en/pro/programs/drugs/eap_mn.aspx

OHIP+ and the Ontario Drug Benefit

A new digital tool makes the more than 4,400 medications covered through the ODB program formulary searchable by brand or generic name, ingredient or Drug Identification Number (DIN).

Drugs that may be covered through the EAP may not currently show up on the search tool.  The ministry is undertaking work to ensure they will in the coming months.

In the interim, we encourage you to visit our website which has EAP Reimbursement Criteria for Frequently Requested Drugs.

www.health.gov.on.ca/en/pro/programs/drugs/pdf/frequently_requested_drugs.pdf

If you are unable to find the information that you require regarding an EAP request, please contact Ontario Public Drug Programs:

E-mail: EAPFeedback.MOH@ontario.ca
Phone: 416-327-8109 or 1-866-811-9893
Fax: 416-327-7526 or 1-866-811-9908

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 30, 2017 from 12:00-1:00 pm. Click on the link below to access the webinar.

https://ali.health.gov.on.ca/r2t1000mnvl/

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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