Free prescription drugs for anyone under 25. That's the simple premise behind Ontario's new OHIP+ plan.
But London mom Jackie Bains says that under OHIP+, filling her son's Attention Deficit Hyperactivity Disorder (ADHD) prescription has become a complicated process.
She arrived at her pharmacist's this week to be told that his prescription for Strattera would only be covered by OHIP+ under certain conditions, one being that her son had to have tried other ADHD drugs first.
"I'm not willing to switch... It's worked wonders for him, so I have no intention of changing this drug," said Bain, adding that her son's pediatrician had always specifically asked that no generic substitutions be made to his prescription.
Bain said her pediatrician now has to submit a request for her son's coverage through Ontario's Exceptional Access Program (EAP), which allows patients to access drugs that aren't among the 4,400 medications covered by the Ontario Drug Benefit Formulary.
Meanwhile, Bain said she had to pay about $190 up-front while she awaits the EAP process.
Previously, she paid about $20 for the prescription through her husband's private insurance.
Now, she says the company is refusing to cover the drug because OHIP+ is supposed to be the primary payer for her son's medication.
"I don't see why taxpayer dollars should be letting the insurance company off the hook," she said.
Complications common, says pharmacist
While London pharmacist Scott Coulter described OHIP+ as a "phenomenal program" overall, he said that situations like Bain's are likely happening in every Ontario pharmacy, every day.
"Here basically we've taken someone who has coverage and put them in a situation where, because of these changes, essentially is paying out of pocket for something they didn't have to pay for before," he said.
"The issue there is that the EAP process is long and convoluted... And so the insurers are denying coverage based on the guidelines that the government set out, and patients are going without or being delayed therapy," he said.
Adding to the complication is the fact that Coulter said he only has access to claims for six days. If a patient fills a prescription on a Thursday, he can re-submit the claim and refund the patient's money up until the following Wednesday.
After that, he says they would have to manually submit a paper claim to the government, which would take longer to process.
What's more, Coulter said that many patients he works with are still paying the same premiums they did before OHIP+ came into effect.
"My frustration with it comes from the fact that these are hardworking Ontario citizens that are in most cases paying premiums for family coverage and are now being denied that coverage."
Time and money
According to the Conference Board of Canada, the introduction of OHIP+ provided prescription drug coverage to 1.2 million Ontarians who previously had no private insurance. It also transferred an additional 2.1 million people who already had private insurance to the public coverage under OHIP+.
Shawn Whatley of the Ontario Medical Association said those numbers represent a mixed blessing.
"We're very happy about the 1.2 million patients, I think that's a real win for patients who really needed help," said Whatley.
"It's too bad that funding is being used to help the 2.1 million patients that already had the drugs that they need."
From a practical perspective, the switch to OHIP+ has also become something of a time suck for doctors, he said.
"I've heard from many physicians that they're being inundated with patients showing up with EAP forms wanting to get them filled out… And the forms take time to fill."
As Bain awaits her own EAP request to be completed, she has her fingers crossed that it will be successful.
"We have a very tight budget and this was an expense that I was definitely not expecting. I had no choice but to fill it because I was running out of prescription... And this isn't a type of medication you can start and stop taking."
In an email statement, the Ontario Ministry of Health and Long-Term Care said that patients who choose to purchase an EAP drug and start therapy in advance of an EAP funding decision are responsible for any out-of-pocket costs.
If the EAP request is approved, the cost of the drug may be reimbursed for up to 30 business days prior to the date the Ministry received it.
Regarding Jackie Bain's situation, they said there is a streamlined EAP form online for prescribers whose patients are already stabilized on a certain medication, and that Strattera is available for this streamlined process.