October 29, 2015

Pangaea Express: ODB Changes Effective October 1, 2015

by Beverley Herczegh, Director

The following Ontario Drug Benefits program changes will go into effect October 1, 2015.

Background:

In April 2015 the Ontario government announced the need to implement cost saving policies to help offset the deficit. In May 2015, OPA, NPAC and MOHLTC were at the table to discuss strategies. Subsequently, the government has announced the following changes.

October 1, 2015:

  • Mark up on drug claims where cost ≥$1000 reduced from 8% to 6%
  • Long Term Care
    Reduction of fee by $1.26 per claim across all geographic areas
    Expect formulary management to come such as delisting certain medications, deprescribing initiatives and eventually a distinct LTC formulary
  • 2-generic No-Sub rule means that going forward, in order for a no sub claim to be paid for by ODB two different generics must have been tried and each must have a documented adverse drug reaction (ADR) on file. Those with one ADR on file and already receiving brand will be grandfathered
  • 5/365 rule requires that the Ministry will only pay 5 dispensing fees per 365 days for a specific list of 112 chronic medications (15 drug classes) find the list here:

Interesting and important notes:

  • 5/365 rule does NOT apply to LTC homes (nursing homes), Ministry funded group homes or those covered on Ontario Works (35 day drug coverage)
  • The reduction in fee for LTC will account for >50% of the targeted savings from LTC with the balance to come from formulary management
  • The 2-generic no-sub rule will pose challenges where patients are using more than one pharmacy
  • The ODB network will not be able to support the 5/365 rule until at least mid-2016. This means the system will not “flag” when a patient record has been billed 5/365 for a specific DIN. Managing this will require manual and investigative effort at pharmacy and will be operating on an honour system (subject to audit) until the network is modified to block fee payments beyond 5/365
  • Despite the 5/365 rule, pharmacies in Ontario must dispense the lesser of the 100 days maximum that ODB will pay or the amount prescribed. The fee charged on any 30 day trial Rx will count as one of the 5 fees
  • Compliance packaging is an uninsured professional pharmacy service which means pharmacies may bill patients who wish to continue to receive weekly or monthly compliance packaging

On-going advocacy

  • Pharmacy in Ontario will continue to push for more expanded scope with these as areas of focus:
    Assessment and treatment of minor ailments
    Expand pharmacist-administered immunizations and injections beyond influenza Extend pharmacist funding for smoking cessation programs to all Ontarians

For further information, please contact Bev Herczegh, Director, The Pangaea Group or by phone at 647-407-3592

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