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OHIP + Changes in Effect for Those Under the Age of 25 – What This Means for Private Plan Members & Employers

OHIP + Changes in Effect for Those Under the Age of 25 – What This Means for Private Plan Members & Employers

OHIP + changes take effect today, which means big changes for prescription coverage of children and youth under the age of twenty-five.

The two main changes to OHIP + are as follows:

  • The Ontario government will still be offering benefits for the 4400 drugs it covers at no cost to those children and youth twenty-four and under WITHOUT a private drug plan.
  • Those WITH a private plan (including insured, ASO and HSA plans) will no longer be covered and must claim prescriptions through their private drug plan.

These changes are a rollback of a program that was introduced in January of 2018 when the government said that many prescription drugs would be covered by the government rather than a private plan, which is defined as any employer, group or individual plan.

What this means for private plan members

Besides having to claim prescriptions, you will also need to determine whether your private plan covers the prescription costs your child needs or whether your private plan covers the drug at all.

There will be no coordination of benefits between private plans and OHIP+ even if a drug is not covered on the individual’s private drug plan. For example, if the private drug plan covers an 80% coinsurance, employees will be required to pay 20% of the cost of the drug, whereas someone who has no private coverage, will receive 100% overage through OHIP+ (assuming it is one of the covered OHIP+ drugs).

What if you have a child on an EAP or LU drug?

Also, it is important to note that for claimants currently taking an Exceptional Access Program (EAP) drug or Limited Use Program (LU) drug through OHIP+ which requires special authorization by their insurance company,  they may be required to provide proof of OHIP+ coverage approval before their private plan (ie: employer-sponsored group benefits plan) pays for that drug. Most insurers have put measures in plans to allow these claimants to transition from OHIP+ back to their private employer-sponsored plans.

If you have a child on an EAP (Exceptional Access Program) drug through OHIP+, you should have received a letter from the government (in addition to the doctor) notifying you of this change effective April 1, 2019.

A few questions that you can ask your insurer if you are not sure whether this change could interrupt your child’s drug coverage:

  1. Is the drug that my child is being prescribed considered a special authorization drug?
  2. If it does require special authorization, what is needed (i.e., a copy of the EAP approval letter) to satisfy any requirements that the insurer may have?
  3. What will be my out of pocket co-pay on these drugs?

If you have a child/youth that requires a drug(s) at a significant cost and it is not covered, or not covered entirely by your private drug plan, you can also apply for the Trillium Drug Program for financial assistance.

What this means for employers

Employers will likely see a rise in the number of drug claims that employees are submitting and a potential increase in costs. Claims for children/youth are usually 12-13% of all claims according to Express Scripts Canada. This may be a good opportunity to review your current employee benefits plan. If you have any further questions about the changes to OHIP +, JWL Benefits would be happy to answer any of your questions. Contact us today!

More information is also available from the Ministry of Health (MOH) FAQs for patients at the following link:

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