FAQs About OHIP+ Redesign Update
*Credit Ministry of Health and Long-Term Care Drugs and Devices Division
1. What are the upcoming changes to OHIP+?
Starting April 1, 2019, the government is focusing OHIP+ benefits on children and youth who do not have a private plan. Children and youth 24 years of age and under who are OHIP-insured, but who do not have a private plan, will continue to receive coverage for eligible prescription medications through OHIP+.
Children and youth 24 years of age and under who have a private plan will access prescription medications through their private plan*, like they did prior to the launch of OHIP+ on January 1, 2018.
Households with high out-of-pocket prescription drug expenses, that include children and youth who are covered under a private plan, can apply to the Trillium Drug Program. The Trillium Drug Program is available to all OHIP-insured Ontarians who have high prescription drug costs compared to their household income. To find out more about the Trillium Drug Program and eligible prescription costs please visit: www.ontario.ca/trilliumdrugprogram or call the Trillium Drug Program at 416-642-3038 (Toronto area) or toll free at 1-800-575-5386.
*Children and youth 24 years of age and under who are eligible for the Ontario Drug Benefit program (ODB) through other eligibility criteria, such as social assistance or home care, will continue to receive prescription drug benefits through the Ontario Drug Benefit program, regardless of whether they have a private plan.
2. Why is the government making changes to OHIP+?
The government is focusing OHIP+ benefits on children and youth 24 years of age and under who do not have a private plan. This change recognizes the important contribution of private insurers and employers in the provision of health benefits to Ontarians.
These changes come into effect on April 1, 2019. Until then, OHIP+ will continue in its current form, providing children and youth aged 24 years and under who are OHIP insured coverage for eligible prescription medications through the Ontario Drug Benefit (ODB) Program.
3. Why is the government not picking up the cost that my private plan does not cover?
The government is focusing OHIP+ benefits on children and youth 24 years of age and under who do not have a private plan. This change recognizes the important contribution of private insurers and employers in the provision of health benefits to Ontarians. In general, private plans cover more drugs than the Ontario Drug Benefit (ODB) program, therefore, children and youth could have access to more medications through their private plan than they do under the ODB program.
4. When will the changes to OHIP+ take effect?
The changes come into effect April 1, 2019.
5. What will be considered a private plan?
A private plan means an employer, group or individual plan, program or account, however described, that could provide coverage for drug products, including the provision of funding that could be used to pay for drug products, regardless of the following:
• the private plan covers the particular drug for which coverage is sought,
• the child or youth or another person captured under the private plan is required to pay a co- payment, deductible, or premium, or,
• the child or youth has reached their annual maximum under the private plan and no further coverage is available.
6. What will happen if the child/youth is not covered for a specific drug through their private plan? Can they then access OHIP+?
Children and youth 24 years of age and under who have a private plan will not be eligible for OHIP+ regardless of whether:
• the private plan covers the particular drug for which coverage is sought,
• the child or youth or another person captured under the private plan is required to pay a co-
payment, deductible, or premium, or,
• the child or youth has reached their annual maximum under the private plan and no further
coverage is available.
Children and youth 24 years of age and under who have a private plan will access drug coverage through their private plan, as they did prior to the launch of OHIP+.
Households with high out-of-pocket prescription drug expenses, that include children and youth who are covered under a private plan, can apply to the Trillium Drug Program. The Trillium Drug Program is available to all OHIP-insured Ontarians who have high prescription drug costs compared to their household income. To find out more about the Trillium Drug Program and eligible prescription costs please visit: www.ontario.ca/trilliumdrugprogram or call the Trillium Drug Program at 416-642-3038.
7. What happens if a child/youth is currently taking a drug that has been approved by the Exceptional Access Program (EAP)?
Children and youth aged 24 years of age and under who are OHIP insured and who do not have a private plan will maintain their OHIP+ eligibility and therefore, continue to have access to their EAP medication until the expiry date on their EAP approval letter.
Children and youth aged 24 years of age and under who have a private plan and have accessed drug funding through the Exceptional Access Program as part of OHIP+ may now require prior authorization for some medications from their private plan before coverage will be granted. If this applies to you, you may want to contact your private plan today to make sure any needed documentation is completed prior to April 1, 2019.
For those who have a private plan:
- Pharmacies will be able to submit claims which do not require prior authorization by the privateplan, directly to the private plan, as they were doing prior to January 1st, 2018
For claims requiring prior authorization by the private plan, the Ministry is working with the
Canadian Life and Health Insurance Association and its member companies to ensure that a transition back to the private plan minimizes disruption to recipients and administrative burden to clinicians.
8. I have a private plan but my out-of-pocket expenses are high. What should I do?
Households with high out-of-pocket prescription drug expenses, that include children and youth who are covered under a private plan, can apply to the Trillium Drug Program. The Trillium Drug Program is available to all OHIP-insured Ontarians who have high prescription drug costs compared to their household income. Households enrolled in the Trillium Drug Program have an annual deductible (approximately 4% of the household net income), which must be paid before drug benefits are funded through the Ontario Drug Benefit program.
Please refer to the “Guide to Understanding the Trillium Drug Program” to see if TDP is right for you before applying. The TDP guide and application form are available on-line on the ministry’s website: www.ontario.ca/trilliumdrugprogram.
If you have any questions about TDP, please contact the Trillium Drug Program at 416-642-3038 (Toronto area) or toll free at 1-800-575-5386.
9. If a child/youth is entitled to receive drug benefits through Ontario Works or the Ontario Disability Support Program, will they be fully covered or will they have a co-pay?
Children and youth 24 years and under who are eligible for the Ontario Drug Benefit (ODB) program because they receive social assistance benefits, regardless of whether they have a private plan, will maintain their benefits through the ODB program with no co-pay and no deductible.
10.If my private plan doesn’t fully cover a drug funded under the Exceptional Access Program (EAP) and I apply to the Trillium Drug Program, do I still have to apply to the EAP?
Yes. Enrollment in the Trillium Drug Plan means the Ontario Drug Benefit Program will help to pay for your eligible prescription drug costs, after you have paid an annual deductible. Some drugs, not on the Formulary, require approval by the Exceptional Access Program to be covered. An authorized prescriber would need to submit an EAP request on behalf of the Trillium Drug Program recipient and the request would need to be approved by the ministry.
To find out which drugs are covered through the Ontario Drug Benefit program, visit: www.ontario.ca/RxChecker.
11.How do I get reimbursed if I have paid out-of-pocket for prescription drugs covered by OHIP+?
If you paid out-of-pocket for an eligible Ontario Drug Benefit Program prescription, you can submit your receipts to the ODB program for reimbursement.
For children and youth aged 24 and under who are OHIP insured and have paid out-of-pocket for ODB eligible prescriptions dispensed prior to April 1, 2019, the ODB eligible receipt will be reimbursed irrespective of whether the OHIP+ recipient has a private plan.
For children and youth aged 24 and under who have paid out-of-pocket for ODB eligible prescriptions dispensed on or after April 1, 2019:
- If the person aged 24 or under is OHIP insured and does not have a private plan, the ODBeligible receipt will be reimbursed.
- If the person aged 24 or under has a private plan, but is eligible for ODB under another ODBeligibility stream, including Ontario Works, Ontario Disability Support Program, Home Care, Long- Term Care, Homes for Special Care, Community Homes for Opportunity or the Trillium Drug Program, then the receipt will be reimbursed, subject to any deductible or co-pay.
• If the person aged 24 or under has a private plan, and is not eligible for ODB under another ODB eligibility stream, then the receipt needs to be submitted to their private plan for reimbursement.
Reminder for receipts that are being submitted to ODB:
- Mail your original eligible prescription receipts to the Ontario Drug Benefit (ODB) program forprocessing.
- Make sure you include your Ontario health card number when submitting your prescriptionreceipts to the ODB program for reimbursement.
ODB program mailing address:
Ontario Drug Benefit Program P.O. Box 384, Station D Etobicoke ON M9A 4X3
Households with high out-of-pocket prescription drug expenses, that include children and youth who are covered under a private plan, can apply to the Trillium Drug Program. For details on Trillium Drug Program please refer to question 8 above.
12.Will contributions made by pharmaceutical manufacturers for patients who are enrolled in Patient Support Programs (PSPs) or have a brand name drug card be considered a private plan?
These will not be considered a private plan under the regulation.
13.Is the Non-Insured Health Benefits Program (NIHB) considered a private plan?
The NIHB is a federally funded plan and is not considered a private plan under the regulation. Patients eligible for NIHB can receive benefits through NIHB as they did prior to the introduction of OHIP+ on January 1, 2018, or they may continue to access benefits through OHIP+, if they are not covered by a private plan.
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