Listeners participated in a live panel session addressing OHIP+, the recently announced expansion of the Ontario drug program to cover young people who are younger than 25 years-old.

1. 1
Unpacking OHIP+
What will it mean for patients?
June 14, 2017

2. What does OHIP+ offer children and
young adults with rare disorders?
Nigel S B Rawson, PhD
Eastlake Research Group, Oakville, Ontario
Canadian Health Policy Institute, Toronto, Ontario

3. Affordability of rare disorder drugs
“We had to turn it down and say no because
of the price tag”
“There’s that feeling of helplessness: I may
lose her because I don’t have enough money
to save her.”
Globe & Mail, May 19, 2017
Will OHIP+ help parents like this?

4. What the government says about OHIP+?
 Liberals “are making sure that every young
person across the province has access to the
medications they need to stay healthy, feel
better and live full lives”
 They “are easing parents’ worries, while
making life more affordable for them”
 Access to medicines will be improved “by
eliminating financial barriers to prescribed
drugs”

5. OHIP+ will only cover drugs in the
OPDP formulary
 General Benefit unrestricted use list: almost 4,000
products ― OPDP pays <$1 for 73%; <$5 for 87%;
>$100 for 1.6%
 Limited Use list: 940 drugs with criteria restricting
access to patients with specific disease characteristics
or to a defined treatment period ― OPDP pays <$1
for 48%; <$5 for 77%; >$100 for 5.8%
 Exceptional Access Program: 127 drugs with detailed,
frequently complex, access criteria; many are
biotechnological products ― often expensive

6. Drugs most commonly dispensed
Children under 12 Older children & young adults
Antibiotics Antibiotics
Anti-asthma drugs Anti-asthma drugs
ADHD drugs ADHD drugs
Analgesics Antidepressants
Cough and cold remedies Contraceptives
Anti-allergens

7. CDR recommendations for rare disorder
drugs
 55 CDR recommendations for 42 rare disorder
drugs submitted between 2004 and February 2016
 19 submissions were for 16 drugs for rare genetic
conditions
 13 of the 19 received negative reimbursement
recommendation
 Resubmissions for two drugs led to revised CDR
assessments later in 2016
 8 of the submissions (42%) now have positive
recommendations

8. Brand name Disorder treated Reimbursement
recommendation
OPDP
listing
Replagal Fabry disease Negative No
Fabrazyme Fabry disease Negative No
Elelyso Gaucher disease Negative No
Vpriv Gaucher disease Positive No
Zavesca Gaucher disease Negative No
Myozyme Pompe disease Positive No
Aldurazyme Mucopolysaccharidosis I Negative No
Elaprase Mucopolysaccharidosis II Negative No
Vimizim Mucopolysaccharidosis IVA Positive* No

9. Brand
name
Disorder treated Reimbursement
recommendation
OPDP
listing
Kalydeco CF (G551D mutation) Positive EAP
Kalydeco CF (CFTR gating mutations) Positive No
Kalydeco CF (R117H CFTR gating mutation) Positive No
Afinitor TSC-associated renal angiomyo-
lipoma
Negative EAP
Afinitor TSC-associated subependymal giant
cell astrocytoma
Negative EAP
Diacomit Dravet syndrome Positive EAP
Kuvan Phenylketonuria Positive* EAP
Ilaris Cryopyrin-associated periodic
syndromes
Negative No
Soliris Atypical hemolytic uremic
syndrome
Negative EAP
Juxtapid Homozygous familial hyper-
cholesterolemia
Negative No

10. Listing to access
 Kalydeco/Diacomit: access usually reasonable
 Afinitor: access only after surgery tried
 Kuvan: harsh access criteria has led to no patient
having access
 Soliris: usually reserved for acute patients and
those who have had a kidney transplant

11. BC AB SK MB ON QC NB NS PE NL
Replagal
Fabrazyme
Elelyso
Vpriv
Zavesca
Myozyme EDS ES SA ES
Aldurazyme
Elaprase
Vimizim
Kalydeco G551D SA EDS EAP SA ES ES
Afinitor TSC EAP
Diacomit SA EDS EAP ES SA ES ES
Kuvan EDS EAP ES
Ilaris
Soliris EAP
Juxtapid ES

12. Conclusions
 Formulary chiefly limited to lower-cost generics
 Children with common conditions whose
parents have no current provincial or private
coverage will benefit most from OHIP+
 Children with rare genetic disorders for whom
new innovative drugs are becoming available are
unlikely to see much benefit from OHIP+
 For those that do, coverage will stop at age 25
 Advocacy remains essential

13. How do Ontario children and young
adults access prescription drugs?
Chris Bonnett, MHSc, PhD (Cand.)
H3 Consulting / hthree.ca
CORD / Toronto / June 14, 2017

14. In ten minutes…
1. Special drug coverage for children and young adults across Canada
2. Estimates of coverage in Ontario: provincial and private drug plans
3. Potential therapeutic classes relevant to children and young adults
4. Considerations and questions
5. Paying for drugs: OHIP+ conclusions

15. Provincial Special Drug Coverage
Children and Young Adults
Prov Special Drug Programs Eligibility Notes
BC None
AB Child Health Benefit Low income (< $26,023, +); < age 19/21
SK Children’s Drug Plan,
Insulin Pump (IP)
CDP: $25 per drug; < age 15.
IP: < age 26.
MB Insulin Pump < age 18.
ON OHIP+ (proposed) Universal < age 25; ODB+EAP drugs; no cost
QC None
NB Growth Hormone Deficiency (GHD) < age 19; 20% up to $20/drug, up to
$500/family/yr.
NS Insulin Pump < age 25
PEI GHD; Immunization; IP GHD, Imm: < age 18. IP: < age 19.
NL Select Needs Plan; IP SN: GHD up to 18. IP: < age 25.
Sources: (1) Clement FM, et al., 2016. Canadian Publicly Funded Prescription Drug Plans, Expenditures and an Overview of
Patient Impacts. University of Calgary, School of Public Policy. https://obrieniph.ucalgary.ca/system/files/comparison-of-
canadian-publicly-funded-drug-plans-for-alberta-health-feb-1-2016.pdf. (2) Provincial government websites.

16. Public: Unclear
Government drug spending (2014, ages 0 – 24): $146,005,000 1
Incremental provincial drug spending: $319,000,000
Proposed annual drug spending (2018): $465,000,000 2
Total ON Beneficiaries (ages 0 – 24): 3,914,000 3
Percent of total population (13,448,000): 29 3
Per capita (ages 0 – 24): $119 (2018, implied)
OPDP Coverage Estimates 4
ODB Programs 3.94 mm (28%)
• Beneficiaries (ages 0 – 19) 400,000 eligible
• Beneficiaries (ages 0 – 24) 244,000 (60%) claim
Other public 0.24 mm (2%)
Private insurers 7.74 mm (55%)
Uninsured 2.24 mm (16%)
Total 14.16 mm (105% of population)
Sources: (1) CIHI NHEX 1975-2016 Open Data. (2) Ontario government News Release, May 23, 2017. (3) Statistics Canada,
2016 Census. (4) 2015/16 Report Card for the Ontario Drug Benefit Program. Private insurance coverage is unreliable.

17. Private: We know even less
• Typical private drug plan prescription drug coverage is for children to
age 18, except age 23 or 25 if a full time student, or if physically or
mentally incapable of self-support. 1
• Most plans reimburse 100%, 80% or 90% of a much broad(er) formulary,2
though few have limits on out-of-pocket spending.
• Current private drug spending for ages 0 to 24: unknown.
• Telus Health, ages 0 – 29: 3
• 30.7% of claimants account for 12.4% of total eligible costs.
• OHIP+ may save 8% to 11% of drug claims, defer other cost controls. 4
Notes: (1) There are over 100,000 private health plans, and many variations on eligibility for both members and drugs.
(2) PDCI Market Access reported that their database of private drug plans reimbursed 3,300 more DINs than the ODB
formulary. See Pharmacare Costing in Canada, March 2016, p.21. (3) Telus Health, 2016 Data Trends. (4) M. Sullivan,
Cubic Health, LinkedIn blog May 1, 2017; F. Naranjo, Collins Barrow, quoted in Cdn HR Reporter, May 23, 2017

18. Top 10 Therapeutic Classes
Children and Young Adults
Class Rank / Name
Avg. Cost
$ per script
Notes
2 Diabetes 80 Metformin only generic in top 10; 14% trend
4 Depression 41 Higher use offset by lower cost generics
5 Asthma 73 Most products brand only; generic fill 35%
6 Infections 33 Rank 3rd in utilization; -8% trend
9 Cancer 503 Biggest pipeline; 12% trend
10 ADHD 96 Mostly generic, but 14% trend
11 Multiple sclerosis 1,847 Most often diagnosed in young adults
41 Rare diseases 4,686 Few products currently, but 42% trend
48 Cystic fibrosis 3,216 Orkambi® could benefit 50% @ $260,000/yr
Source: Express Scripts Canada, 2016 Drug Trend Report. http://www.express-scripts.ca/knowledge-centre/drug-trend-
reports. Rank is by annual claim cost.

19. Considerations and Questions
General
1. Who are “most in need and least able to pay”? 1
2. No detail / certainty on estimated cost. What assumptions?
3. Will impacts (intended and not) of new drug coverage be measured?
Private Drug Plans
1. Insured plans will not see immediate cost reductions; ASO will. 2
2. Young plan members are usually low cost; rates may increase for others.
3. Will some employers exclude members under age 25, even though it’s
unclear what OPDP formulary won’t cover?
4. Unknown future costs: Could Employer Health Tax be increased? 3
Notes: (1) 2017 Ontario Budget. http://www.fin.gov.on.ca/en/budget/ontariobudgets/2017/. (2) Insured plans (pooled or
experience-rated) are typical for smaller employers (<50 to 100 employees). ASO (Administrative Services Only) plans
are self-insured by larger employers. (3) 2017 Budget (Table 6.14) estimates EHT revenue at $5.9 billion for 2016-17.

20. OHIP+ Conclusions
1. OHIP+ coverage is unique in Canada. Other provinces have specific
targets: low income families or certain diagnoses. Some have co-pays.
Quebec offers consolidated, consistent universal coverage model.
2. Budget speaks of those in need, but message then changes to equity
and supporting notion of universal pharmacare. Immediate purpose
and longer-term goals are unclear.
3. Quick implementation means consultation may be welcomed…or
discouraged so that Ministry can meet its deadline…but something
will have to be implemented before the 2018 election.
4. A welcome surprise to employers. Biggest impact will be on ASO plans
with large, recurring claims….but some employers could choose to
eliminate coverage for Ontario plan members under age 25.

21. How do Ontario children and young
adults access prescription drugs?
Chris Bonnett, MHSc, PhD (Cand.)
H3 Consulting / hthree.ca
CORD / Toronto / June 14, 2017

22. In ten minutes…
1. Special drug coverage for children and young adults across Canada
2. Estimates of coverage in Ontario: provincial and private drug plans
3. Potential therapeutic classes relevant to children and young adults
4. Considerations and questions
5. Paying for drugs: OHIP+ conclusions

23. Provincial Special Drug Coverage
Children and Young Adults
Prov Special Drug Programs Eligibility Notes
BC None
AB Child Health Benefit Low income (< $26,023, +); < age 19/21
SK Children’s Drug Plan,
Insulin Pump (IP)
CDP: $25 per drug; < age 15.
IP: < age 26.
MB Insulin Pump < age 18.
ON OHIP+ (proposed) Universal < age 25; ODB+EAP drugs; no cost
QC None
NB Growth Hormone Deficiency (GHD) < age 19; 20% up to $20/drug, up to
$500/family/yr.
NS Insulin Pump < age 25
PEI GHD; Immunization; IP GHD, Imm: < age 18. IP: < age 19.
NL Select Needs Plan; IP SN: GHD up to 18. IP: < age 25.
Sources: (1) Clement FM, et al., 2016. Canadian Publicly Funded Prescription Drug Plans, Expenditures and an Overview of
Patient Impacts. University of Calgary, School of Public Policy. https://obrieniph.ucalgary.ca/system/files/comparison-of-
canadian-publicly-funded-drug-plans-for-alberta-health-feb-1-2016.pdf. (2) Provincial government websites.

24. Public: Unclear
Government drug spending (2014, ages 0 – 24): $146,005,000 1
Incremental provincial drug spending: $319,000,000
Proposed annual drug spending (2018): $465,000,000 2
Total ON Beneficiaries (ages 0 – 24): 3,914,000 3
Percent of total population (13,448,000): 29 3
Per capita (ages 0 – 24): $119 (2018, implied)
OPDP Coverage Estimates 4
ODB Programs 3.94 mm (28%)
• Beneficiaries (ages 0 – 19) 400,000 eligible
• Beneficiaries (ages 0 – 24) 244,000 (60%) claim
Other public 0.24 mm (2%)
Private insurers 7.74 mm (55%)
Uninsured 2.24 mm (16%)
Total 14.16 mm (105% of population)
Sources: (1) CIHI NHEX 1975-2016 Open Data. (2) Ontario government News Release, May 23, 2017. (3) Statistics Canada,
2016 Census. (4) 2015/16 Report Card for the Ontario Drug Benefit Program. Private insurance coverage is unreliable.

25. Private: We know even less
• Typical private drug plan prescription drug coverage is for children to
age 18, except age 23 or 25 if a full time student, or if physically or
mentally incapable of self-support. 1
• Most plans reimburse 100%, 80% or 90% of a much broad(er) formulary,2
though few have limits on out-of-pocket spending.
• Current private drug spending for ages 0 to 24: unknown.
• Telus Health, ages 0 – 29: 3
• 30.7% of claimants account for 12.4% of total eligible costs.
• OHIP+ may save 8% to 11% of drug claims, defer other cost controls. 4
Notes: (1) There are over 100,000 private health plans, and many variations on eligibility for both members and drugs.
(2) PDCI Market Access reported that their database of private drug plans reimbursed 3,300 more DINs than the ODB
formulary. See Pharmacare Costing in Canada, March 2016, p.21. (3) Telus Health, 2016 Data Trends. (4) M. Sullivan,
Cubic Health, LinkedIn blog May 1, 2017; F. Naranjo, Collins Barrow, quoted in Cdn HR Reporter, May 23, 2017

26. Top 10 Therapeutic Classes
Children and Young Adults
Class Rank / Name
Avg. Cost
$ per script
Notes
2 Diabetes 80 Metformin only generic in top 10; 14% trend
4 Depression 41 Higher use offset by lower cost generics
5 Asthma 73 Most products brand only; generic fill 35%
6 Infections 33 Rank 3rd in utilization; -8% trend
9 Cancer 503 Biggest pipeline; 12% trend
10 ADHD 96 Mostly generic, but 14% trend
11 Multiple sclerosis 1,847 Most often diagnosed in young adults
41 Rare diseases 4,686 Few products currently, but 42% trend
48 Cystic fibrosis 3,216 Orkambi® could benefit 50% @ $260,000/yr
Source: Express Scripts Canada, 2016 Drug Trend Report. http://www.express-scripts.ca/knowledge-centre/drug-trend-
reports. Rank is by annual claim cost.

27. Considerations and Questions
General
1. Who are “most in need and least able to pay”? 1
2. No detail / certainty on estimated cost. What assumptions?
3. Will impacts (intended and not) of new drug coverage be measured?
Private Drug Plans
1. Insured plans will not see immediate cost reductions; ASO will. 2
2. Young plan members are usually low cost; rates may increase for others.
3. Will some employers exclude members under age 25, even though it’s
unclear what OPDP formulary won’t cover?
4. Unknown future costs: Could Employer Health Tax be increased? 3
Notes: (1) 2017 Ontario Budget. http://www.fin.gov.on.ca/en/budget/ontariobudgets/2017/. (2) Insured plans (pooled or
experience-rated) are typical for smaller employers (<50 to 100 employees). ASO (Administrative Services Only) plans
are self-insured by larger employers. (3) 2017 Budget (Table 6.14) estimates EHT revenue at $5.9 billion for 2016-17.

28. OHIP+ Conclusions
1. OHIP+ coverage is unique in Canada. Other provinces have specific
targets: low income families or certain diagnoses. Some have co-pays.
Quebec offers consolidated, consistent universal coverage model.
2. Budget speaks of those in need, but message then changes to equity
and supporting notion of universal pharmacare. Immediate purpose
and longer-term goals are unclear.
3. Quick implementation means consultation may be welcomed…or
discouraged so that Ministry can meet its deadline…but something
will have to be implemented before the 2018 election.
4. A welcome surprise to employers. Biggest impact will be on ASO plans
with large, recurring claims….but some employers could choose to
eliminate coverage for Ontario plan members under age 25.

29. Durhane Wong-Rieger, PhD
President
Canadian Organization for Rare Disorders
June 2017
OHIP+
What Patients are Saying

30. Durhane Wong-Rieger, PhD
President
Canadian Organization for Rare
Disorders
June 2017
OHIP+
What Patients are Saying

31. 31
Unpacking OHIP+
What will it mean for patients?
June 14, 2017