UNDERSTANDING THE TRILLIUM DRUG PROGRAM

Transcription

1 J. L. Glennie Consulting Inc. UNDERSTANDING THE TRILLIUM DRUG PROGRAM 1

2 2 OBJECTIVES Provide an overall understanding of the Trillium Drug Program (TDP) in the context of the broader Ontario Public Drug Programs Develop an understanding of relevant eligibility policies as applied by the TDP Review selected case studies to better understand TDP processes

3 3 DISCLAIMER My comments are my own and do not represent the position of any organization to which I have belonged in the past. NOTE: Detailed questions are best addressed via TDP resources and/or directly with TDP staff. J.L. GLENNIE CONSULTING INC. CONFIDENTIAL

4 4 FIRST -IMPORTANT FACTS ABOUT THE TDP Applies to Ontario ONLY! Not a drug program it is a financial assistance program based on financial need high out of pocket drug costs (+/ private plan or type of plan) Provides access only to drugs already covered by ODB for their core recipients ALSO need to meet the same clinical criteria (i.e., use of previous therapies) Patient must demonstrate out of pocket drug costs before applying to TDP

5 SO, WHERE DOES TDP FIT? J.L. GLENNIE CONSULTING INC. CONFIDENTIAL 5

6 6 OPDP THE BIG PICTURE The OPDP includes one major, several smaller drug programs (for special patient populations), and the TDP for financial assistance. OPDP ON Drug Benefit (ODB) Program + Trillium Drug Program New Drug Funding Program Special Drugs Program Visudyne Program Inherited Metabolic Diseases Program RSV Program for Infants

7 7 DRUG COVERAGE WITH TDP ODB Program ODB Formulary EAP TDP General Benefit Limited Use Conditional Listing

8 8 SCOPE OF FUNDING HC APPROVALS VS. ODB FUNDING NOTE: Not all marketed drugs are covered by ODB 22,000+ 3,200+

9 APPLYING FOR TDP J.L. GLENNIE CONSULTING INC. CONFIDENTIAL 9

10 10 BACKGROUND ON THE TDP Purpose: to help people who have high prescription drug costs relative to their household income A financial assistance program (not a program that funds a different list of drugs) Eligibility process 2 parts: #1: apply for financial assistance qualification #2: pursue drug access Simple (GB): via MD prescription Moderate (LU): via MD prescription + appropriate LU code Complex (EAP): submit for approval per the pre set clinical criteria for drugs already funded

11 11 HOW TO TELL IF A PRODUCT IS FUNDED BY ODB 1) Search the ODB e formulary 2) Check the EAP list/reimbursement criteria (i.e., prior authorization system) ml 3) Check the drug submission status reports e_subm.html 4) Check the not funded drugs list (last updated Dec 2011) unding.pdf

12 12 ELIGIBILITY RULES Parameter ODB TDP Eligibility Live in ON + have a valid ON Health Card Live in ON + have a valid ON Health Card Application process Varies Annual Proof of existing drug expenditures required? Age/other qualifying factors -no - senior (>65yo) - Ontario Works, ODSP - Long-Term Care/Home for Special Care resident - Home Care Services YES!!! - don t fall into any ODB age/other qualifying groups - No private health insurance OR private insurance does not cover 100% of prescription drug costs AND - household drug costs are 4% of household s total net/after tax income Deductible and/or co-pay - Variable, depending on recipient category - Deductible (divided quarterly) - $2 co-pay/rx after deductible paid

13 13 AM I ELIGIBLE FOR TDP? BACK OF THE ENVELOPE Calculation of the deductible (see pg. 5 of Guide) Family of 4 (3 adults, 1 child) Total household income $75K + $50K + $10K = $135K Subtract $20K; multiply result by 0.045; add $500 to result; subtract $200 from result (family of 4) Deductible = $5475/y i.e., need to have total household drug costs > $5475/y to make it worthwhile to apply for TDP J.L. GLENNIE CONSULTING INC. CONFIDENTIAL

14 14 TDP APPLICATION PROCESS (1) FIRST: See TPD brochure and application form (on line) Annual, paper based application process Approval based on out of pocket drug expenditures 4% of household net income ( deductible ) Expenditures must occur before TDP application will be considered Full disclosure of private insurance coverage information

15 15 TDP APPLICATION PROCESS (2) Review by TDP Approval notification from TPD Informed of quarterly deductible On line adjudication process once approved Still have out of pocket costs until TDP deductible reached

16 16 POTENTIAL PHARMACY LEVEL SCENARIO FOR A PRIVATELY INSURED PATIENT TDP eligibility approved Patient takes Rx to Pharmacy Pharmacy adjudicates via private insurer Pharmacy adjudicates balance via TDP

17 CASES STUDIES J.L. GLENNIE CONSULTING INC. CONFIDENTIAL 17

18 18 TYPES OF DRUGS COVERED UNDER EAP Clinical and cost effectiveness in a specific subpopulation of patients Management of potential off label use Wide range of outpatient/community based therapies Some biologics (RA, PsO, PsA, AS, UC, etc.) Some MS medications (inj) Some oral oncology medications (Note: IVs under New Drug Funding Program)

19 19 CASE STUDY #1 FUNDED BIOLOGIC Scenario: Remicade for rheumatoid arthritis; high out of pocket drug costs Step Action Comments 1) Drug coverage Verify if product covered by OPDP Need to meet EAP criteria to undertake step 3) below; publicly available 2) TDP application Submit application form, documentation Include private coverage information, receipts to date 3) EAP application MD submits to EAP At same time as TDP application MD should indicate TDP application in process 4) TDP approval Inform pharmacy and MD of TPD registration MD to f/u with EAP Supply TPD with paper receipts for expenditures b/t TDP application and approval timeframes

20 20 EAP CRITERIA FOR REMICADE IN RA For the treatment of rheumatoid arthritis in patients who have: Severe active disease (5 swollen joints and rheumatoid factor positive and/or radiographic evidence of rheumatoid arthritis) despite the optimal use of various formulary disease modifying anti rheumatic drugs (DMARDs)*. *Optimal use of DMARDs include: Methotrexate (20 mg/week) for at least 3 months and leflunomide (20 mg/day) for at least 3 months in addition to an adequate trial (3 months) of at least one combination of DMARDs; or, Methotrexate (20 mg/week) for at least 3 months and leflunomide in combination with methotrexate for at least 3 months. If the patient could not receive adequate trial(s) of methotrexate and/or leflunomide due to contraindication(s) or intolerance(s), the nature of contraindication(s) or intolerance(s) must be provided along with details of trials of other DMARDs or clear rationale why other DMARDs cannot be considered.

21 21 CASE STUDY #1 FUNDED BIOLOGIC Scenario: Remicade for rheumatoid arthritis; high out of pocket drug costs Step Action Comments 1) Drug coverage Verify if product covered by OPDP Need to meet EAP criteria to undertake step 3) below; publicly available 2) TDP application Submit application form, documentation Include private coverage information, receipts to date 3) EAP application MD submits to EAP At same time as TDP application MD should indicate TDP application in process 4) TDP approval Inform pharmacy and MD of TPD registration MD to f/u with EAP Supply TPD with paper receipts for expenditures b/t TDP application and approval timeframes

22 22 CASE STUDY #2 UNFUNDED PRODUCT Scenario: Neulasta for chemotherapy induced neutropenia; high out of pocket drug costs Step Action Comments 1) Drug coverage 2) Remaining options Verify if product covered by ODB Continue with level of current coverage ODB Unfunded drugs list

23 23 CASE STUDY #3 NEW DRUG PRODUCT Scenario: Fycompa (perampanel) for partial onset seizures; high out of pocket drug costs Step Action Comments 1) Drug coverage Verify if product covered by ODB 2) TDP application Submit application form, documentation Status of Single Source submissions list No funding decision as of Nov 25/13 On spec ; no guarantees must meet financial criteria for TDP submit out of pocket receipts for Fycompa so far (+ any other ODB covered drugs used in household) 3) EAP application MD submits to EAP At same time as TDP application On spec ; no guarantees; will be held until funding decision is made will need to meet whatever clinical criteria are developed under EAP, if TDP approved

24 24 FURTHER INFORMATION ABOUT THE TDP b/opdp_trillium.aspx TDP forms Inquiries regarding the Trillium Drug Program should be directed to: P.O. Box 337, Station D Etobicoke, Ontario M9A 4X3 Tel : Fax : Toll Free : E mail : trillium@ontariodrugbenefit.ca

25 25 REMEMBER -IMPORTANT FACTS ABOUT THE TDP Applies to Ontario ONLY! not a drug program it is a financial assistance program based on financial need high out of pocket drug costs (independent of type of private plan) Provides access only to drugs already covered by ODB for their core recipients ALSO need to meet the same clinical criteria (i.e., use of previous therapies) Patient must demonstrate out of pocket drug costs before applying to TDP

26 THANKS! J.L. GLENNIE CONSULTING INC. CONFIDENTIAL 26