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The Ontario Drug Benefit Program - Overview for Residents

The Ontario Drug Benefit Program - Overview for Residents. Sherri Elms RPh ACPR Oct 2014. Objectives. Outline the population served by the ODB program and costs incurred by patients Describe the various classes of ODB coverage Coverage pearls by class Group sharing.

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The Ontario Drug Benefit Program - Overview for Residents

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  1. The Ontario Drug Benefit Program - Overview for Residents Sherri Elms RPh ACPR Oct 2014

  2. Objectives • Outline the population served by the ODB program and costs incurred by patients • Describe the various classes of ODB coverage • Coverage pearls by class • Group sharing

  3. What is a “formulary”? • “In medicine, a listing of prescription drugs approved for use.” • Hospitals and insurers will have their own “lists” • Hospital and public insurers have more restrictive plans. • Formularies developed based on: • Therapeutic efficacy • Safety • Cost effectiveness vs. listed alternatives • Impact on other healthcare services

  4. The Ontario Drug Benefit Program - Who is covered?

  5. The Ontario Drug Benefit Program - Cost to Patients

  6. The Ontario Drug Benefit Program - Cost to Patients • PLUS the first $100 (i.e. deductible) in prescription costs each year (August)

  7. The Ontario Drug Benefit Program - Cost to Patients • For All Recipients • Co-pay varies from store to store – shop around • Fee PER Rx – prescribe 100 days at a time

  8. Trillium – What is it? Provides access to the ODB formulary for the working poor without a drug plan • Deductible dependent on income and # of dependents – due quarterly – patients must put out some money. (max 4% net income) • “other assets” not considered – just income – line 236 on tax return • Forms on line: http://www.health.gov.on.ca/english/public/forms/form_menus/odb_fm.html (or Google trillium ODB or in eForms)

  9. Trillium Charts

  10. Trillium Deductible • Single 2 3 >3 • Need to spend $40-60/month on Rx’s before Trillium kicks in. (paid quarterly)

  11. Trillium Deductible • Single 2 3 >3 • Need to spend $140-160/month on Rx’s before Trillium kicks in. (paid quarterly)

  12. Trillium – when? • Who should you consider? • Families • Diabetics • Post MI • Asthmatics • Chronic Pain

  13. The ODB Maze • Regular Formulary Status • Covered, no bureaucracy • Limited Use (LU) Codes • Require an LU number • Exceptional Access Program • Written Request (“Section8”) • Telephone Request Service (TRS) • The Special Drugs Program

  14. The ODB Maze • Regular Formulary Status • Covered, no bureaucracy • Limited Use (LU) Codes • Require an LU number • Exceptional Access Program • Written Request (“Section8”) • Telephone Request Service (TRS) • The Special Drugs Program

  15. Limited Use Codes (LU) Limited Use drugs may: • have the potential for widespread use outside the indications for which benefit has been demonstrated ie quinolones; • be useful but are associated with predictable severe adverse effects and a less toxic alternative is available as a benefit; • be very costly and a lower-cost alternative is available as a general benefit. Codes available on the ODB website Google “odb formulary search”

  16. The ODB Maze • Regular Formulary Status • Covered, no bureaucracy • Limited Use (LU) Codes • Require an LU number • Exceptional Access Program • Written Request (“Section8”) • Telephone Request Service (TRS) • The Special Drugs Program

  17. Exceptional Access – Written request • Formerly “Section 8” • Application process: • Written request, form available at: http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/GetAttachDocs/014-4406-87~4/$File/4406-87E.pdf or Google ODB Exceptional Access or eForms • Support for diagnosis (specialist reports, tests) • Formulary agents tried or reasons for inappropriateness • Evidence supporting the use of the requested agent (literature, specialist suggestion) • Turn around time 4-6 weeks

  18. EAP – written request - hints • http://www.health.gov.on.ca/english/providers/program/drugs/pdf/frequently_requested_drugs.pdf • Google “ODB frequently requested drugs”

  19. Exceptional Access Program • Telephone Request Service • Telephone based approval process based on predetermined criteria • Approximately 40 drug products for specific, often urgent, indications are available • Can be completed by MD or delegate

  20. Exceptional Access (TRS cont’d) • 1-866-811-9893 or 416-327-8109 • Information required: • CPSO number • Patient’s health card number • “other pertinent patient information” (have the chart) • For a list: • http://www.health.gov.on.ca/english/public/pub/drugs/trs/trs_guide.pdf • Google “eaptrs”

  21. Exceptional Access (TRS cont’d) • Examples: • LMWH for bridging • Ciprodex drops for otitis externa with a perforated tympanic membrane or resistance to other agents • Injectable antibiotics • Palliative care medications • Use EAP if you are not recognized as a palliative care specialist • “… terminal illness and has chosen outpatient palliative services. Life expectancy is < 6 months … “ • See the web, mostly injectable products

  22. Summary – What you need to know • ODB Coverage • Seniors, social assistance, disability, Trillium • Cost • $2 or $6.11 per Rx plus $100 deductible OR 4% net income paid quarterly • ODB Formulary Coverage Types • Regular benefit • LU Codes • Exceptional Access Program • Written Request • Telephone Request Service

  23. “No Substitution” Claims • MOHLTC will cover the higher cost interchangeable product when “medically necessary” • Must: • Handwrite “No Sub” Complete, sign and forward to the RPh and Health Canada “Canada Vigilance” (ADR) form • http://www.hc-sc.gc.ca/dhp-mps/alt_formats/pdf/medeff/report-declaration/ar-ei_form-eng.pdf

  24. Extemporaneous Preparations • Definition • “product prepared by a pharmacist … pursuant to a prescription” • CANNOT be used to work around coverage • Topicals • base must be a covered product, can add only set ingredients (LCD, menthol, salicylic acid, hydrocortisone etc) OR salicylic acid or LCD in vaseline or lanolin • Will not cover 2 creams mixed together. • write Hydrocortisone “x”% pdr in “select antifungal “ cream

  25. PPI’s Rabeprazole (Pariet plus generics), pantoprazole magnesium (Tecta) Covered – no LU necessary Statins All covered Coverage Pearls

  26. Analgesics Narcotics Most covered, EXCEPTIONS: Fentanyl Patch LU 201 only covered if other long acting have failed OxyNeo – EAP only – must have failed 2 other agents OxyContin (generic) – not covered Tramadol/Tramacet not covered Submissions WILL NOT be considered Acetaminophen covered Coverage Pearls

  27. Antibiotics Not covered: Doxycycline fluoroquinolones without LU CAP, COPD, stepdown from IV, allergy Antihistamines/Decongestants None Can use doxepin 10mg hs, if sedation not a problem Nasal Steroids Ciclesonide (Omnaris)(once daily) Coverage Pearls

  28. Dabigatran/Rivaroxaban/Apixaban 431/435/438 Atrial Fibrillation when: TTR with warfarin is <65% INR monitoring is not available Exclusion Criterea eGFR < 30mL/min Valvular disease Prosthetic valves Coverage Pearls

  29. Oral Hypoglycemics Biguanides Metformin (not Glumetza) Sulfonylureas Glyburide, gliclazide MR (Diamicron MR) Glucosidase Inhibitors Acarbose – LU 175, 176 Coverage Pearls

  30. DPP-4 Inhibitor Sitagliptin (Januvia) Linagliptin Saxagliptin Combination Janumet (bid formulation of sitagliptin and metformin) TZD (glitazones) New patients - Only under the EAP – telephone request Coverage Pearls

  31. Insulin Rapid Acting Toronto, LisproHumalog – covered AspartNovoRapidNovoRapidFlexTouch – LU 389 (3 or more injections per day) Intermediate Acting and Mixes 30/70, NovoMix 30 – covered Long Acting NPH, DetemirLevemirLevemirFlexTouch, GlargineLantus, Solostar - covered Coverage Pearls

  32. ASA 81mg not covered Gabapentin/pregabalin now covered – no restrictions Concerta (long acting methylphenidate) covered Advair, Symbicort LU 330 – asthma (not COPD) Celecoxib LU 316 – OA, failed acetaminophen or gi bleed LU 317 – gi bleed or intolerant to 3 other NSAIDs Coverage Pearls

  33. Smoking Cessation Champix, Zyban now covered with LU 423 Alternative – nortriptyline 25-75mg pohs x 2 weeks before quit date then x 12 weeks after (efficacy similar to Zyban) “Low dose” products often not covered Metoprolol 25mg Atenolol 25mg Fentanyl 12mcg patch Nitroglycerin 0.2mg patch Coverage Pearls

  34. Questions/discussion Burning questions about anything! Drug References: www.prescribersletter.com www.Rxfiles.ca Best Science Medicine Podcast - BS without the BS By Dr James McCormack and Dr Michael Allan - iTunes

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