The Ontario Drug Benefit Program - Overview for Residents - PowerPoint PPT Presentation

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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