How One Court Win Made OHIP Out-of-Country Coverage Harder to Get

Alex Shved took the Ontario Health Insurance Plan to court, and he won. Then the province rewrote the rule he had won under. It's an unusual sequence of events, and it happens to be the clearest way to understand how OHIP out-of-country coverage for drugs now works, and why patients and the government see the change so differently.

The bottom line

Ontario has amended its regulations so that out-of-country drugs are publicly funded only when the drug is already funded in Ontario, but access here is temporarily unavailable or delayed. That closes the door on using public money to get a Health Canada-approved treatment abroad while it waits in the provincial funding queue. Patients in that gap now depend on clinical trials, private funding, or time.

Key takeaways

Alex Shved, 37, has Stage 4 melanoma, and his oncologist sought OHIP funding for TIL therapy in Florida at roughly US$600,000.

Ontario's Divisional Court found OHIP had offered no real basis for its denial and ordered it to reconsider.

OHIP then refused a third time, and the province announced amended rules on October 8, 2026.

Out-of-country drugs are now funded only if they are already funded in Ontario but temporarily unavailable or delayed.

A version of TIL therapy called lifileucel was approved for sale by Health Canada in 2025 and is still under review for public funding.

Why did OHIP refuse to pay for TIL therapy?

Shved is a 37-year-old father of two living with Stage 4 melanoma, the most serious form of skin cancer, which in his case has spread beyond where it started. His oncologist asked OHIP to fund tumour-infiltrating lymphocyte therapy, or TIL therapy, at a clinic in Florida at a cost of roughly US$600,000, according to The Canadian Press, as published by CTV News.

TIL therapy works by removing part of a patient's tumour, pulling out the immune cells that have already found their way inside it, growing those cells into the billions in a lab, and infusing them back so they can attack the cancer. A version called lifileucel was approved for sale by Health Canada last year, yet it is still going through the reviews that decide whether provincial drug plans will pay for it, a process that can take years.

OHIP denied the request, arguing in part that routinely funding out-of-country drugs while they are under review here would weaken the incentive for drug makers to take part in Canada's review process. Shved took the province to Divisional Court and won, with the court finding that OHIP had offered no real basis for that reasoning and ordering it to reconsider.

What changed in Ontario's drug funding rules?

After the ruling, OHIP rejected Shved's request a third time. Health Minister Sylvia Jones then announced that the province had amended its drug funding rules to clarify that out-of-country drugs will be publicly funded only when the drug is already funded in Ontario, but access is temporarily unavailable or delayed. Jones said the government is exploring a mutually satisfactory resolution in Shved's individual case, though Shved has said it is unclear to him what that would mean.

The two sides read the change very differently. The province describes it as a clarification of when out-of-country drugs qualify. Shved says Ontario has effectively blocked public funding for out-of-country drug treatment in response to his case. And if you follow the new rule through to its end, it turns out to be circular, since a drug must already be funded in Ontario to qualify, and getting funded here is the very process that takes years.

Why does public drug coverage lag behind Health Canada approval?

Most people assume that once Health Canada approves a drug, the public system pays for it. In fact, approval and payment are two separate steps, and it is one of the clearest examples of who decides what in Canadian health care. Health Canada decides whether a drug is safe and effective enough to be sold. Public drug coverage comes later, after Canada's Drug Agency reviews whether the drug offers good value, the provinces negotiate the price together through the pan-Canadian Pharmaceutical Alliance, and each province decides whether to list it.

Four separate steps stand between a drug's approval and public coverage. Ontario's new rule only funds drugs abroad once all four are done.

Each of those steps can take months, and the whole path can stretch over years. The same split between approval and payment shapes stories as different as Lecanemab coverage in Canada and what Canada's generic Wegovy approval actually means. Health Canada's oversight also continues after approval, as readers who received a letter about the TAVNEOS review found out.

What does this mean for patients in Ontario?

Most people never think about out-of-country funding until a serious diagnosis makes a treatment abroad look like the best option. For patients in Ontario, OHIP out-of-country coverage for drugs is now narrower and clearer at the same time. If a therapy is approved by Health Canada and still waiting in the funding queue, the province will not pay for you to receive it in another country in the meantime.

The Exceptional Access Program, which funds some unlisted drugs case by case, does not fill that gap for cancer drugs, since it only considers cancer drugs already approved for provincial funding through the national and provincial processes. Patients in that position are left with clinical trials, private fundraising, or waiting. Gaps between what is approved and what is paid for show up well beyond cancer care, as the Canadian Dental Care Plan report card showed when it explained why some patients still get surprise bills.

Which questions should you ask your care team?

If you or someone you love is facing a serious diagnosis and a recommended treatment is not funded, your care team is the best place to start. Asking early and keeping records makes every one of these processes easier to navigate, even while you are still waiting for a specialist appointment.

Ask about clinical trials. Find out whether the treatment is available through a trial in Canada, which can provide access without the drug cost.

Ask where the treatment sits in the funding review. Knowing whether a drug is at the national review, price negotiation, or provincial listing stage gives you a sense of the wait.

Ask for a patient navigator. Many cancer centres have a navigator or drug access coordinator who handles exceptional access requests.

Ask about special access. Health Canada's Special Access Program lets doctors request drugs that are unavailable for sale in Canada for serious conditions, though it authorizes access and leaves the cost as a separate question.

Keep copies of everything. Save letters, decisions, and dates, since reconsiderations move faster with a clear paper trail.

What happens next for out-of-country requests?

Jones has said the province is exploring a resolution in Shved's case, and the amended rules now govern future out-of-country requests for drugs. The funding reviews for Lifileucel are continuing, and their outcome will decide whether Ontario patients can eventually receive it through the public system at home. Anyone affected by a denial should ask their care team about reconsideration options as soon as the decision arrives.

Frequently asked questions

Does OHIP out-of-country coverage still exist?

OHIP out-of-country coverage still exists for some insured services that need prior approval. For drugs, the rule is now narrow, since Ontario will fund an out-of-country drug only when it is already funded in the province but temporarily unavailable or delayed. Treatments approved by Health Canada yet still under funding review no longer qualify.

Is TIL therapy approved in Canada?

A version of TIL therapy called lifileucel was approved for sale by Health Canada in 2025. Approval means it can be sold here, while public funding is a separate decision that comes after national review and price negotiation. Lifileucel is still going through those funding reviews, a process that can take years.

What is Ontario's Exceptional Access Program?

The Exceptional Access Program helps eligible people get coverage, case by case, for drugs that are not listed on the Ontario Drug Benefit Formulary. Only a doctor or nurse practitioner can apply. For cancer drugs, it only considers treatments already approved for provincial funding through the national and provincial review processes.

What is Health Canada's Special Access Program?

The Special Access Program lets health care professionals request drugs that are unavailable for sale in Canada for patients with serious or life-threatening conditions when standard treatments have failed, are unsuitable, or are unavailable. Health Canada reviews each request individually. The program authorizes access to the drug, and paying for it is a separate question.

Your next step

A serious diagnosis comes with a hundred decisions, and the system is easier to navigate with a care team you can actually reach. The Medimap Health Hub explains more about how coverage works in Canada, and Medimap can help you find family doctors and clinics near you, so the next conversation about your options happens sooner.

Disclaimer: This article is for general information only and is not medical advice. It does not replace a conversation with a doctor or other qualified health professional who knows your history. If you think you are having a medical emergency, call 911 or go to the nearest emergency department.