Since Ontario rolled out its new pharmacare program for youth on Jan. 1, multiple media reports have detailed the challenges faced by some people in transitioning to public drug coverage from their private plan.

The examples include a mother who, according to the Brantford Expositor, found that while the provincial program doesn’t cover Fluoxetine, a medication for her child’s obsessive-compulsive disorder, her private insurance had also dropped it on Jan. 1. The Expositor noted the woman has since applied to the government’s exceptional access program to cover the medication and, in the meantime, her insurer has agreed to pay for the drug for at least a month until her case proceeds.

Read: What will the transition from private plans to OHIP+ look like?

As for why an insurer would stop covering a drug, private health plan strategist Suzanne Lepage notes a private insurer wouldn’t want to duplicate coverage. “Private plans were designed to wrap around public coverage; therefore, they will typically not cover a drug that will be covered by a provincial drug plan,” she says.

Karen Voin, vice-president of group benefits and anti-fraud at the Canadian Life and Health Insurance Association, says the insurance industry worked closely with the Ontario government in advance of the Jan. 1 launch of the new program in order to ensure a smooth transition from private coverage. Indeed, the insurance industry voluntarily agreed to a six-month period during which it will continue to consider coverage for certain types of drugs: antibiotics, blood thinners and medications with low approval rates from the exceptional access program.

The industry has also made efforts to provide information about the changes, says Voin. “There was very focused attention on communication prior to Jan. 1, and I would say that it most definitely happened through insurers who are reaching out to patients who were taking a medication that would need to go through the EAP process and creating that awareness that they needed to apply and work with their clinician to do that.”

Read: Sounding Board: A primer on OHIP+ for private payers

The insurance industry has also been active in encouraging patients to speak with their doctors to determine whether they required exceptional access and move that process along before Jan. 1, adds Voin. “And I would also say that the ministry itself was very active on working with clinicians as well, so I think it’s important not to lose track that there was a lot of effort being put into trying to draw that awareness to patients in advance of Jan. 1.”

If patients do find themselves in a situation where there will be a delay in drug coverage, they should talk to the Ministry of Health and Long-Term Care, their doctor and their insurer, says Voin. “There’s no guarantee in terms of how that will work, because every insurer will have developed their own methodology around that, because the program is first payer as of Jan. 1. But in the interest of being helpful, I think insurers are really trying to be as flexible as possible in the first few months to really help patients through that.”

The Ontario Pharmacists Association has also been hearing reports of both the new youth pharmacare program and private insurance not covering a medication, says Allan Malek, the organization’s executive vice-president and chief pharmacy officer.

Malek notes prescribers, such as physicians and nurse practitioners, did receive notice prior to Jan. 1 to identify patients who may be eligible for exceptional access so they’d be ready when the new program took effect. But Malek says that didn’t happen in some cases for a variety of reasons, including a lack of time on the prescriber’s part and the work involved in checking on individual patients.

Read: Will OHIP+ bring meaningful savings for private plans?

Another issue pharmacists are seeing, according to Malek, stems from the fact that the Ontario Drug Benefit formulary hasn’t included pediatric drug formulations because seniors and those on social assistance haven’t needed them. The association, he notes, had raised issue up with the ministry. “There may need to be some degree of a formulary review, and I don’t know when that’s going to happen or how that’s going to happen,” says Malek. “And we’re asking for it, we’ve raised it. I’m just waiting for an opportunity to sit down and have that discussion.” 

Laura Gallant, a spokesperson for Ontario Health Minister Eric Hoskins, said the government has received suggestions of drugs to add to the Ontario Drug Benefit formulary from clinician groups and noted the ministry continues to review and assess those requests. “The decision to fund a drug under the Ontario public drug programs is based on recommendations arising from a series of drug product reviews, including reviews by Health Canada and national and/or provincial expert clinical committees,” said Gallant.

Another issue is limited-use drugs under the provincial formulary that require a code, says Malek. He notes  pharmacists can’t enter the code and says getting it from prescribers can lead to extra delays.

Malek says the association has asked the ministry for permission to do one-time overrides and enter the code in order to ensure continuity of care.

Read: The impact of Ontario’s public drug program changes on private plans

“I keep saying to them, ‘Look, that sounds logical. It’s a very logical approach. See how big the problem is before you implement a solution.’ But you’re telling people, you’re out there communicating that this is a great thing, that it’ll be seamless, and it’s not. And now you’re getting patients frustrated at the point of care and they’re not able to get their medications. They may get a day or two advance for free from the pharmacist to cover until the pharmacist can get the code that they need, but now they have to come back, which is an inconvenience.”

There are, however, override codes for pharmacists to use in specific situations, according to Gallant, who noted “the ministry remains open and willing to continue working with stakeholders in an attempt to identify and address potential transition issues, including looking into different ways to help OHIP+ eligible patients transition from private to public coverage for exceptional access program drugs that are required immediately.”

While Malek supports the new youth pharmacare program, he’s leery of the growing pains. “We expected some hiccups, but it’s difficult and pharmacists, unfortunately, bear the brunt of it because they’re the messenger. They’re not trying to block access. They can only work within the regulations that are in play,” he says.

“I think it’ll all work out. I think it is a big change,” he adds, noting that thousands of claims are going through seamlessly. “But typically, what bubbles to the surface are the glitches, the hiccups, and I think we’ll get there, but we need collaboration from all the players.”

Read: Universal pharmacare program could save $4.2B: report

Copyright © 2022 Transcontinental Media G.P. Originally published on
See all comments Recent Comments

Joe Nunes:

Government makes promise to be popular and win votes but is woefully unprepared to deliver effectively.

This is a story I have never seen before.

Wednesday, January 24 at 11:25 am |

Rosemary Hatnay:

I believe doctors/medical community were not adequately informed of the impact of OHIP+ on their qualifying patients. There is an additional administrative burden on their practice as they receive multiple calls and faxes to correct prescriptions in order for prescriptions to be covered. I personally experienced a situation where my child was prescribed a limited use drug for asthma. The pharmacist could not fill the prescription through OHIP+ without the pediatrician’s approval of the limited use code. I ended up paying out of pocket for the drug as it was not a prescription that could wait to be filled. This drug was previously covered by my private plan. After multiple attempts and a follow up visit at the pediatrician’s office the pharmacist received the necessary approval and I had to return to the pharmacy for a refund. This was not a positive experience.

In addition, given my background, I provided my pediatrician’s office when I was there for the follow-up visit with my son, an educational session on how OHIP+ works (i.e. ODB formulary, limited use codes, private plans second payor etc.). He had many frustrated parents who were unable to fill prescriptions.

Wednesday, January 24 at 12:51 pm |

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