Zero tolerance? OCP dismisses complaint from teacher forced to use PPN pharmacy for specialty drug

The Ontario College of Pharmacists has dismissed a complaint from a teacher who was forced to move her speciality drug prescription to an in-house pharmacy by her insurer—despite the college’s opposition to closed preferred provider networks (PPNs).Back in 2024, high-school teacher Amy Miller filed a complaint against three pharmacists who are directors of MemberRx, the in-house pharmacy for the Ontario Teachers Insurance Plan (OTIP), after she was told that she would lose coverage of her medication unless she moved her prescription from her local pharmacy to MemberRx.But as reported by the Globe and Mail, the college’s disciplinary panel issued a decision on Jan. 14 to take no action against the directors, stating that it had no jurisdiction over PPN and calling the complaint a matter of “policy rather than professional regulation.” The panel also said “there is currently no legislation or other mechanism” to prohibit pharmacists from participating in PPNs.Miller relies on Humira, an injectable biologic drug, to treat her ankylosing spondylitis arthritis. But without her insurance coverage, the medication would cost her more than $30,000 a year.MemberRx was set up for OTIP by Cubic Health Inc., a Toronto-based consulting firm. Miller’s complaint alleged there was a conflict of interest, given that the three directors named in the complaint (Xiaofei Huang, Bishoy Khalil and Michael Sullivan) also held paid positions at Cubic Health. But the respondents denied there was any conflict of interest, stating that all of MemberRx’s profits go back into the plan. The college also found there was “insufficient information” demonstrating a conflict of interest.Critics also note the OCP’s dismissal of the complaint appears to go against the college’s own policy. Back in July 2024, the OCP board of directors adopted a “zero tolerance” statement against closed PPNs, stating that these care models “pose potential risk of harm to patients, contravene established ethical principles guiding the profession and conflict with standards of quality patient care.”“I don’t know why they would have a zero-tolerance policy, and then not be able to enforce it,” Ontario Pharmacists Association president Justin Bates told the Globe.But the defending pharmacists argued OTIP had a “fiduciary obligation to balance providing comprehensive coverage in a sustainable manner” and that a vertically integrated PPN was “necessary to achieve” these cost savings. “We have confidence in the professionalism and care demonstrated by MemberRx throughout this process,” Sullivan, Cubic Health’s CEO and one of the MemberRx directors subject to the complaint, said in a statement to the Globe. “In its review, the Panel found no evidence that MemberRx limited a patient’s choice of pharmacist, disrupted continuity of care, or placed business interests ahead of the patient’s wellbeing.”Meanwhile, the Ontario government announced last November it would soon introduce legislation to ban closed PPNs. The province said its legislation would adopt the “Any Willing Provider” framework, which would force insurers to give the opportunity for any pharmacy to join the PPN if they are willing to meet the insurer’s financial terms.Miller, for her part, told the Globe she plans to appeal the college’s decision.

Zero tolerance? OCP dismisses complaint from teacher forced to use PPN pharmacy for specialty drug

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