As Ontario prepares to roll out its new pharmacare program for youth on Jan. 1, plan sponsors and members will be watching to see how the transition to the public plan from private coverage will work.
Of particular concern is the relationship between private plans and the exceptional access program, which facilitates access to drugs not listed on the Ontario Drug Benefit formulary. According to the Ministry of Health and Long-Term Care, Ontarians under age 25 will also be able to apply to qualify for coverage under the exceptional access program.
The ministry noted that due to the time it can take to reach a decision on exceptional access funding, insurers will continue to cover certain drugs without a rejection letter until June 30, 2018. Those drugs fall into the categories of antibiotics and anti-infectives, blood thinners and drugs with low approval rates under the exceptional access program.
According to the ministry, beginning on July 1, 2018, people will have to be assessed and denied coverage for all exceptional access program and transition drugs before applying to have a medication covered by a private plan.
“There will be a reasonable amount of claims that will actually be denied through EAP because, again, the member doesn’t meet the criteria for EAP and yet the private plan might have open coverage, for instance, for those drugs,” says Helen Stevenson, president and chief executive officer of Reformulary Group Inc.
While Stevenson is optimistic the transition period will be long enough, she notes the issue does involve significant numbers of people. “It’s a lot of people, potentially. I think the estimates were around four million people. Now, not every one of them are taking drugs that require an exceptional access and some of these are being streamlined,” she says.
“So I’m going to say hopefully that’s enough time, but it is a pretty substantial change that’s going on. Picking up, the adjudication systems now have to be set so that they take OHIP+ as the first payer and, if it’s not covered by the ODB program, than the private plan will continue to pay for it.”
For the majority of Ontario youth, transitioning to the program will be seamless, adds Stevenson.
“In theory, very little will change,” she says, noting the Reformulary Group conducted an analysis of its database of 10 million Canadians, of which 350,000 are Ontarians under age 25. “And the vast majority of drugs are antibiotics, asthma drugs, for instance. There certainly are some drugs, speciality drugs like biologics . . .. But for the antibiotics and the others, [for] the vast majority of people, it will be seamless.”