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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

September 25, 2017

Colleagues,

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

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

OHIP+ and Medications for Children and Youth

As a result of OHIP+, starting January 1, 2018, all children and youth aged 24 and under who are OHIP insured will automatically be covered under the Ontario Drug Benefit (ODB) program.

OHIP+ will ensure that eligible children and youth have no out of pocket costs for all benefits currently covered through the ODB program. This includes over 4,400 drug products listed on the ODB Formulary/Comparative Drug Index and additional medications eligible for funding through the Exceptional Access Program (EAP).

Children and youth often have very different medical treatment and drug therapy needs from adults. The ministry is working with clinicians and specialty groups who oversee the medical care of children and youth to ensure there is a smooth transition to OHIP+ on January 1, 2018.

How to get ready

Prescribers that specialize in treating children or provide care to children and/or youth are encouraged to familiarize themselves with the kinds of drugs and drug products covered on the ODB Formulary to help patients access medications that are appropriate and covered on January 1, 2018.  You can search the Formulary at: www.formulary.health.gov.on.ca/formulary/

Exceptional Access Program and OHIP+: Children and Youth Pharmacare

The EAP facilitates publicly funded access for ODB recipients (including all Ontarians age 24 and who qualify for OHIP+ starting January 1, 2018) in exceptional circumstances to:

  • Drugs not listed on the ODB Formulary;
  • Drugs listed on the ODB Formulary but not for the patient’s indication; or
  • Where ODB Formulary drugs were ineffective, not tolerated or where no listed alternative was available.

To receive coverage for an EAP drug, a funding request must be submitted by the patient’s prescriber with specific information on the patient’s medical circumstance to support funding of the particular drug. Requests are reviewed on a case-by-case basis and categorized by priority – taking into consideration how quickly a drug is needed, the type of drug, and the condition for which the drug is being used. If the request is approved, the child or youth will be fully covered for the cost of the medication.

The ministry is planning a streamlined EAP request process for OHIP+ eligible patients who are currently stable on a medication for a chronic condition (whether previously paying out-of-pocket or through private insurance). The ministry will confirm details regarding this process in the next few weeks.

In order to ensure seamless coverage on January 1, 2018, the ministry is encouraging prescribers to submit EAP requests for eligible patients as soon as possible. Please feel free to fax full EAP requests to: 1-844-227-6590.

EAP request forms can be found at:
health.gov.on.ca/en/pro/programs/drugs/eap_mn.aspx#3

Additional information on Ontario’s Exceptional Access Program can be found at:
health.gov.on.ca/en/pro/programs/drugs/eap_mn.aspx

More details will continue to be provided regarding OHIP+. We welcome any comments, feedback or advice that you may have regarding OHIP+ and its implementation.

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

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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