The Ontario Government has announced that amendments to the OHIP+ plan are to take effect April 1, 2019.
What is OHIP+?
On January 1, 2018, OHIP+ began. Eligible medications were to be covered by the Ontario Provincial Health Care program for children and youth aged 24 and under, who are covered by OHIP (the Ontario Health Insurance Plan). Enrollment in OHIP+ is automatic and coverage stops on the individual’s 25th birthday.
The new Ontario government announced, soon after they were elected in mid-2018, that they would be modifying the OHIP+ program to reduce the number of eligible children and youth. Under a redesigned OHIP+, eligible children and youth, who do not have private insurance, would continue to receive their medications, through the program, without co-payments or deductibles. For those children and youth who are covered by private insurance, their drugs will be billed to those plans. Just as it was prior to the launch of OHIP+, private insurer will be first payor.
This change will be effective as of April 1, 2019.
How does OHIP+ Work?
If a drug is listed on the Ontario Drug Benefit (ODB) Formulary/Comparative Drug Index and a claimant (without a private medical plan) is eligible for OHIP+ , then that drug would be dispensed with no out of pocket expense at the pharmacy. All that is required is a health card number and an eligible prescription.
Exceptional Access Program (EAP)
Fewer drugs are automatically eligible for coverage through the OHIP+ program than through private plans. Many of those drugs not on the ODB formulary are managed through the Trillium Drug Program’s “Exceptional Access Program (EAP)”. The EAP facilitates access to drugs not listed on the ODB formulary under specific clinical circumstances. Under this program, certain qualifying conditions must be satisfied before a drug is eligible and paid. Individuals eligible for OHIP+ or even those with a private plan who still find that they have significant out-of-pocket expenses, may submit a request for Trillium EAP funding.
The application and approval process through the EAP program can take anywhere between 3 days to 6 weeks, depending on the individual’s medical circumstances and the particular drug involved. For individuals with private coverage, different insurance providers have different guidelines relating to the EAP process and ASSOCIUM can help determine how your provider integrates with the EAP and what options are available to cover high-cost medications.
How will the OHIP+ Changes Affect Me or My Employer?
As of March 1, private plans will, once again, be first payor for drug claims currently submitted to OHIP+. OHIP+ will no longer be a factor to private employee benefit plans. Though there was originally an expectation of reduced extended health care rates, there was not enough time for them to materialize. Going forward, we don’t anticipate much impact to rates once OHIP+ no longer applies to children and youth eligible to be covered by private plans.
Learn More about OHIP+
Contact ASSOCIUM Benefits to find out who may be eligible for alternate funding sources such as the EAP, what medications are covered and how to get it.