Changes to OHIP+ mean some kids will go without life-saving medicine


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8 comments

  1. Lisa

    Thanks for the shoutout to pharmacists in this piece. The reality is that front-line pharmacists have been raising concerns for months around the administration of OHIP plus, but no one seems to pay attention to pharmacists. The advocacy organization for pharmacists in Ontario have also been cozying up to big pharma and government in order to survive funding cuts. Again, no one listens to front line pharmacists. When no one listens to front line pharmacists, stuff like this happens. When our society and health care system decides to value the knowledge, skills and expertise of pharmacists, then we will all be better served.

  2. Mary

    As a Social Worker in the field of educating patients about government drug plans, this is definitely a problem that needs to be addressed. The private insurance should’ve gone back to original coverage rates for the twins after OHIP changed the rules of drug coverage. For adults I support taking expensive biologic medication, I suggest asking their Rheumatologist to apply to the Exceptional Access Program (EAP) for complete government drug coverage, or with assistance from the Insurance company. Is this option available to these children? I don’t know what medication their on of course or if there is an age limit to the EAP?

    • Deborah LEvy

      Thanks for your comments. To clarify, EAP approval does not equate to full government drug coverage. EAP approval is sought for most of the biologics we use in children. EAP approval is required for OHIP+ to pay (for those who are otherwise uninsured) fully without copay. But for those with any private drug coverage, EAP approval requires an application to the Trillium Drug Program for coverage. As above, The Trillium Drug Program will then assess the deductible required to be paid by the family.

  3. Aaron

    Thank you for this informative article. However, it seems to me that the real issue is that the private insurer “Initially… covered 100 percent of the cost” but”now have a $25,000 yearly maximum”. This is a drastic reduction in coverage for a medicine used to treat a rare disease and someone (the employer and insurer) should be accountable for having agreed to or made this change. It would be very interesting to know if this is an isolated incident or if there is a larger pattern of insurers reducing coverage limits after the implementation & changes to OHIP+. I personally believe that it was a ridiculous financial decision to make OHIP+ the “first payer” – Ontario’s healthcare dollars can be better spent than paying something that was already being paid for by private insurance. However, I now much have a much better appreciation for the chaos that that the recent changes have caused… so thank you!

  4. Joel Lexchin

    There are even better solutions. First, make the drug companies justify their prices by having them open their books and show what the development costs for drugs actually are. Second is a national pharmacare program that covers all medically necessary drugs (as determined by an independent panel of healthcare professionals, economists and consumers) for everybody for with no copayments.

  5. Adam Smith

    When OHIP + was introduced, the OMA and many physicians complained about it. But wasn’t that better than the previous system of no coverage? And not physicians continue to complain. Whining by physicians who earn tons of money is simply quite tiresome.

    • Cynthia

      This isn’t whining. The physicians are simply trying to discuss a real issue with this change and how it affects patients requiring expensive biological. I call this being a patient advocate. I also wish they could have default OHIP + as a second coverage plan. But this also creates logistic challenges as various drug plans are set up differently, administered differently. Some require payment upfront and submit for reimbursement and there are plans that can be submitted electronically. This makes coordination of benefits challenging at a pharmacy level. So it’s easy to default to keeping things simple but it hurts this population who relies on high cost medication. I also agree the insurance company in this case should not have changed their coverage but I think there is a clause that they can change at anytime with notice.

  6. Stephanie

    On April 2 I went to get a new aerochamber for my daughter who has asthma. I was told that due to the changes in OHIP+ that took place the previous day, we would have to pay out of pocket. We do have private insurance, but it doesn’t cover aerochambers. I even called them to ask if they would cover it with a doctor’s prescription, nope, they don’t cover them under any circumstances. My family currently “opts in” for family coverage on my husband insurance plan offered through work. Next year, we will opt out because it’s not worth it for us to pay the monthly fee and have less coverage than we would have if we were eligible for OHIP+ (we pay a deductible of 10$ or more on each prescription as well). Are there any petitions we can sign to tell the government we want OHIP+ to be the second payer?

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