OHIP+: Children and Youth Pharmacare – effective January 1, 2018
As of January 1, 2018, all individuals of Ontario who are under the age of 25 and have a valid OHIP card will automatically be covered under the Ontario Drug Benefit (ODB) program – a drug formulary that covers approximately 4,400 drugs. There will be no deductible or co-payment and OHIP+ claims will be adjudicated online at the pharmacy.
The OHIP+ program will:
- Be the first payor of eligible prescription drugs. Medications which are not eligible under the OHIP+ plan may be considered under a private plan
- Provide full coverage of ODB general formulary medications
- Provide coverage for ‘limited use’ drugs – which are drugs reimbursed only when pre-defined medical criteria are met
- Provide coverage under the Exceptional Access Program (EAP) – which provides access to drugs not listed on the ODB; an application must be submitted for consideration from the treating physician
- Not extend coverage for prescriptions incurred out of the province or country
Children and Youth who are currently taking medications which may be eligible for funding under the EAP, will need to apply to ODB for coverage of the EAP medication. To assist with the transition in coverage for EAP medications from a private plan to the ODB program, insurers are providing a transition period from January through June 2018. Many insurers are notifying individuals if coverage may be available under the EAP and directing the individual to apply for funding.
With the introduction of OHIP+, some savings are expected under private plans. Depending on the coverage offered under the private plan, the ages of covered members and the prescription claims of a member’s dependents, savings could range from 1–4%. Generally speaking, insurers are reviewing the impact of OHIP+ with the 2018 renewal. For Extended Health Care plans which are funded on an Administrative Services Only (ASO) basis or Refund Accounting arrangement, the impact will flow through the claims experience. For other fully insured plans, rates may be adjusted at the time of the 2018 renewal.
Your CBA consultant will be able to outline the specifics of how your insurer is handling this change. If you have any questions please feel free to contact your CBA consultant.