Patients First Update: OHIP+ Children and Youth Pharmacare
We are pleased to share this update on OHIP+: Children and Youth Pharmacare (OHIP+) with you.
As the weekly webinars have now ended, the ministry will continue to provide updates through eblasts to ensure individuals receive the information they need regarding OHIP+.
If you have any questions or comments, please feel free to contact the ministry at OHIPplus@ontario.ca.
OHIP+ Activity Since Launch
As of March 16, 2018, there have been more than 2.5 million OHIP+ paid claims processed. This includes antibiotics to treat infections, inhalers for asthma, various insulins, oral diabetic medications and diabetes test strips, epinephrine auto-injectors (e.g. EPIPENs®), and drugs to treat arthritis, epilepsy and other chronic conditions.
Exceptional Access Program
If an OHIP+ recipient needs a drug not listed on the Ontario Drug Benefit (ODB) Formulary, they may be able to get the drug covered under the Exceptional Access Program (EAP).
REMINDER: Prescribers are encouraged to submit EAP requests on behalf of their patients in order to ensure that children and youth do not experience any interruption in access to medicines that are covered through the EAP.
To see if a drug is available through the EAP, please visit the following website: www.ontario.ca/page/check-medication-coverage/
To view a list of EAP medications please see the attached DIN list or visit:http://www.health.gov.on.ca/en/pro/programs/drugs/eap_criteria.aspx
For more information on the EAP, visit https://www.ontario.ca/page/applying-exceptional-access-program#section-0
Limited Use (LU) Products
For some children and youth new to the Ontario Drug Benefit program, the Reason for Use (RFU) code may now be required for certain medications. LU products are listed on the ODB Formulary with specific clinical criteria/conditions for use and will only be reimbursed under the ODB program when those criteria/conditions are met for an ODB eligible recipient (this includes children/youth eligible through OHIP+). For LU products that are not available for funding through the EAP, if a patient does not meet the LU criteria, physicians and nurse practitioners can write “Does not meet LU” on the prescription to prevent pharmacists from calling to ask if a patient meets criteria. Please note that for LU products that are also available for funding through the EAP, private insurers may request that the prescriber apply to the EAP and provide the patient with a rejection letter before the private insurer will consider providing coverage. If an EAP request is not approved, the rejection letter can be forwarded to the patient’s private insurer who may provide coverage (if previously covered).
Check the online eFormulary for LU drugs and criteria:
REMINDER: It is the physician or nurse practitioner’s responsibility to determine whether the patient meets the LU criteria and to provide the Reason For Use (RFU) Code (either verbally, electronically or in written format) with the prescription. There is no application process for LU products other than including the RFU code on the prescription as LU claims are processed directly at the pharmacy.
TEMPORARY FACILITATED ACCESS MECHANISM (RHEUMATOLOGY)
The ministry has collaborated with the Ontario Rheumatology Association (ORA) to implement a temporary facilitated access mechanism. Prescribers identified by the ORA are authorized to prescribe specific biologics for certain rheumatology indications for OHIP+ recipients on a temporary basis without submitting an EAP request. The TFA is only available to provide coverage for certain biologics for select indications when prescribed by approved prescribers for their patients aged 24 years and under.
REMINDER: Physicians on the TFA Rheumatology List of Authorized Prescribers are expected to write the words “Temporary Facilitated Access” or “TFA” on the prescription.
For more information on the TFA, including prescribing requirements, please visit:http://www.health.gov.on.ca/en/pro/programs/drugs/opdp_eo/notices/exec_office_20171214.pdf)
For information on EAP reimbursement criteria of frequently requested drugs including biologics, please visit:(http://www.health.gov.on.ca/en/pro/programs/drugs/docs/frequently_requested_drugs.pdf).
VALVED HOLDING CHAMBERS (VHCs)
VHCs are eligible for ODB recipients 12 years of age or under only. Only one VHC per 365 day period is allowed. Inappropriate VHC claims (i.e., for patients over the age of 12) may be subject to recovery.
REMINDER: Note that VHCs are not deemed interchangeable. A list of VHCs funded by the ODB program is available here:http://www.health.gov.on.ca/en/pro/programs/drugs/opdp_eo/notices/exec_office_20171221.pdf
30 DAY PRESCRIPTION PROGRAM
All ODB program recipients, including those eligible through OHIP+, who are receiving ongoing medications should not have the dispensed quantity reduced as a result of the 30-Day Prescription Program. In most cases, OHIP+ eligible patients may not have a claims history in the Health Network System (HNS) and are likely to have their claims rejected for this reason.
REMINDER: The “NH” Intervention Code should be used to over-ride 30-Day Prescription Program rejections for patients who are receiving ongoing medication therapy and are stable on their treatment regimen.
Visit us online at www.ontario.ca/OHIPplus