ODBA

• ODBA


  Ontario Drug Benefit Act & Regulations
• Ontario's public benefit plan

  • The Ontario Drug Benefit Program
  • The Trillium Drug Program
  • Special Drug Programs
  • The New Drug Funding Program for Cancer Care
  • Inherited Metabolic Disease Program
  • Respiratory Syncytial Virus Prophylaxis for High-Risk Infants Program
  • OHIP+
• The Health Network


  All the Ontario pharmacies are linked to the Ministry of Health and Long Term Care computer system which allows on-line real time claim processing
• The network also informs about


  • Drug interactions
  • Duplicate prescriptions (DP)
  • Potential double doctoring (DD)
  • Inappropriate use of the system
  • Fill to late or too soon
• Formulary Parts


  • Part 1 – Introduction – background, how to use, reimbursement / processes / information / contacts
  • Part 11 – Preamble
  • Part 111-A – Benefits / drugs (ODB / CDI)
  • Part 111-B – OFI
  • Part 1V – not in use
  • Part V – Pharmacologic -Therapeutic Classification
  • Part V1 – Facilitated Access Drugs
  • Part V11 – Trillium Program
  • Part V111– Exceptional Access Program (EAP) – Individual Clinical Review
  • Part 1X – Nutritional products / Diabetic testing
  • Part X – Abbreviations, Tables, Sample forms
  • Part X1 – currently not used
  • Part X11 – Limited Use Products
• ODB Eligibility


  • Member of a 'Designated Class'
  • Insured under Health Insurance Act (OHIP)
  • 65 years of age or older
  • Aged 24 years or under
  • Home care program
  • Residents of LTC or Homes for Special Care
  • Trillium Program
  • Persons entitled to receive drug benefits
  • Ontario Works Act
  • Ontario Disability Support Program Act
• Billing - Plan Codes

  • Code C: Ontario Disability Support Program (ODSP), Assistance for Children with Severe Disabilities
  • Code D: Ontario Works Program (OW), Temporary Care Assistance (TCA), Disability benefits
  • Code P: Home care
  • Code E: Long term care
  • Code H: Homes for special care
• Amount Paid by EO (Executive Officer)


  Drug Benefit Price + Markup + ODB Fee – co-payment = what the EO pays
• ODB fee currently is $8.83
• Mark-up


  • 8% on total cost less than $1000.00
  • 6% on total cost $1000.00 and more
• Co-pays


  • $2.00
  • $6.11 (Patient portion...)
• As of October 1, 2015, a maximum of five (5) dispensing fees are paid to pharmacies for 15 categories of chronic-use medications, to fees per recipient, per drug (by interchangeable category), per 365-day period
• If documented for Compliance packaging or Unit dose dispensing, 2 monthly fees are paid
• Billing Quantity


  • 100 days supply for seniors and those receiving disability benefit
  • Up to another 100 days supply for vacation supplies
  • 1 month (up to 35 days) supply for Ontario Works
  • 2 weeks to 6 weeks, may be even longer for Home care
• Co-payment


  • $2.00 for monthly card-holders + low income seniors
  • $6.11 for higher income seniors
• Deductible


  Higher income seniors pay $100 per year
• Once deductible is paid, co-payment of $6.11 applies
• New seniors, sliding scale deductible depending on birthday falls
• Deductible is based on fiscal year – Aug 1 – July 30
• Income Bracket for Seniors


  • Single senior with annual income less than $19,300 or couple less than $32,300 pays up to $2.00 co-payment
  • Income more than the above, seniors pay $100.00 deductible and up to $6.11 co-payment
• Co-payment is not mandatory, an operator of a pharmacy may charge, or accept payment from, a person in respect of supplying a listed drug product in an amount not greater than the maximum co-payment the executive officer is permitted to subtract
• Trial Quantity


  Limits to 30 day supply on all new Rx or Rx not dispensed in previous 12 months, allows patient to try the med / reduces waste
• Exceptions to Trial Quantity


  • Patient got just enlisted in the health network system but used the drug in the past 12 months
  • Patient will be out of province for more than 100 days
  • Due to some valid reason the patient is unable to return to the pharmacy within the 30 day period
• No Substitution - Patient Choice


  Patient may request more expensive brand, RPh "may charge" the difference from the patient
• No Substitution - Prescriber's Choice

  Prescriber may advise use of a brand product, ministry will reimburse higher-cost brand product through a "no substitution" claim in medically necessary circumstances where an ODB recipient has experienced a significant adverse reaction to a minimum of two (2) interchangeable generic drug products
• Limited Use Products


  Drugs recommended by the Committee to Evaluate Drugs as having value in specific circumstances although they may not be appropriate for general listing in the Formulary, reimbursed under the ODB program only when prescribed for an ODB eligible recipient in accordance with the criteria outlined for each product
• Criteria for LU drugs

  • Have the potential benefit to use it outside the indications for which benefit has been demonstrated
  • May have predictable severe adverse effects and a less toxic alternative is available
  • Very costly and a lower cost alternative is available as a benefit
• Limited Use


  Reimbursement tied to criteria / conditions for use of drug, Physician indicates Reason for Use – RFU number (could be verbally), Expiry of LU depends on the drug
• Additional Benefits


  • Nutritional Products - Sole source of nutrition, MD fills form – kept on file for 10 years
  • Diabetic Testing Agents - Most testing agents are covered, Must be prescribed, May collect difference from patient, Limits per year: Diabetes type I - 3000 strips, type II – 400 or 200 strips
• Exceptional Access Program


  EAP facilitates patient access, in exceptional circumstances, to drugs approved for sale in Canada but not listed on the ODB Formulary, or in situations where Formulary drugs were ineffective or not tolerated, or where no listed alternative was available, the physician must submit a written request and provide the full detail of the patient's case, the drug is usually approved for a period of one year
• Trillium Drug Program


  Helps pay for drugs listed in the formulary to the family members when their annual drug expenses are disproportionately high relative to their income, the amount each family pays is based on the family's total income and the number of persons in the family
• Trillium Drug Program application is required, must meet calculated annual deductible – 4 installments per year, once deductible is met - Rx is $2.00 for ODB drugs
• The OHIP+


  Children and Youth Pharmacare program is available to children and youth age 24 years or younger, regardless of family income, who is not covered by a private plan, the program pays for drugs covered by the ODB Program and the drugs on the Exceptional Access Program, no deductibles or co-payments
• Extemporaneous


  Not equivalent to a manufactured product, internal must contain a solid dosage form of a listed product + no other active ingredient, topical - listed product + no other except those indicated in regulations, injection - prepared under direct supervision of RPh – some restrictions, specific ophthalmic preparations, $0.55 per minute of compounding time is paid
• Extemporaneous Total Cost


  DBP of ingredient + Acquisition cost of any unlisted ingredient + Time, Total the EO will pay: ((EXT. DBP + MU) + Time) + ODB Fee – Co-payment, time is with drug cost NOT fee
• Prescribers of ODB


  • Physicians
  • Dentists
  • Chiropodists / Podiatrists
  • Nurse practitioners
  • Midwives
  • Pharmacists
  • Optometrists
  • Naturopaths
• Cannot refuse to supply a listed drug product to an eligible person, exception - use of professional judgement – harm to patient
• Provincial law


  Legislation that governs Ontario Drug Benefit Program
• Ontario Drug Benefit Program


  • Introduced by Ministry of health
  • One of the largest of drug plans in Canada
  • Pharmacy operators are not obligated to participate & can opt out
• ODB Plan


  Has a formulary that lists products that are considered benefits