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  • Rob Snow

OHIP+ *some conditions apply


It's one of the signature programs of the Wynne government. Behind the curtain, doctors are grumbling.

OHIP+ is Ontario's child and youth pharmacare program. It's an expansion of the Ontario Drug Benefit, covering people up until their 25th birthday. It's supposed to cover 4,400 medications and pharmacy services, no co-payments or deductibles. But speak with any doctor or pharmacist and it doesn't take long to learn *some conditions apply.

This week the Ontario Medical Association (OMA) issued a statement to its 40,000 member physicians. It's a warning to your doctor - get ready. They are about to be buried under an avalanche of paperwork trying to navigate OHIP+.

Under OHIP+ the government is the first payer.

Even if parents are blessed with gold plated workplace drug plans, it matters no more. The government pays first. If OHIP+ doesn’t cover the drug, parents with private coverage can seek reimbursement from their insurance providers. They also apply for government coverage through a supplementary program, called the Exceptional Access Program (EAP). As the OMA indicates, insurance providers have been "assisting with coverage for some drugs without an EAP rejection letter."

That's about to end.

This added obstacle, the EAP, is a massive source of frustration. From the doctor's office to the pharmacy, both ends are drowning in red tape and delays. And it's about to get much worse.

Dr. Barry Dworkin, an Ottawa based family doctor and a weekly guest on my radio show, explained it this way: "Now the insurance company is going to ask every one of those patients to go see their physician to be assessed to see whether they still need to take that medication, which they likely will be. And then they'll need to make an EAP form completion to send to the government to get the rejection letter, so they can send it to the insurance company, who will then continue to provide the coverage. It's a downloading of the effort onto the patient and the physician, filling out forms that are completely unnecessary, when the patient was already being cared for."

This is a great deal for an insurance company. It's gone from being the first payer for millions of workers, to the payer of last resort. One can only wonder when workplace premiums will be reduced to match.

The delays are bound to hurt patients, according to Dr. Dworkin. "This is going to damage and interrupt the treatment process for the patient, because of the EAP turnaround. Now every single prescription that someone is on will have to go through OHIP+, get either rejected or accepted. And if they are rejected, forms have to be completed and then sent off again, so they can be rejected again."

Pharmacare is not a new issue, but it's the cause du jour from Queen's Park to Parliament Hill.

OHIP+ is often touted as the road map for a national program. Its architect, Dr. Eric Hoskins (Ontario's former health minister), bailed on Premier Wynne to lead up the national pharmacare advisory council. (While collecting a tidy $800 per diem.)

A word of advice before jumping on the OHIP+ bandwagon: read the fine print. *Some conditions apply.

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