OHIP+ transitioning to second payer

OHIP+, Ontario’s new drug benefit program for children and youth, will become the second payer for those with private insurance coverage.

Effective  January 1, 2018  the previous Liberal government agreed to fully cover the cost of prescription drugs eligible under the Ontario Drug Benefit (ODB) program for people under the age of 25, with no deductible or co payment, regardless of family income.

However, Ontario’s new Minister of Health and Long-Term Care, Christine Elliott, announced in June that drug claims for children and young adults must be paid through private insurance first, with the government covering all remaining eligible prescription costs. Children and youth who are not covered by private benefits would continue to receive their eligible prescriptions at no cost.

No timeline was provided by the Conservative government for when OHIP+ will transition to second payer. For now, most Exceptional Access Program (EAP) drugs and approximately 4,400 drugs covered by the ODB will continue to be funded by OHIP+ for claimants under the age of 25 until the Ministry of Health works through the changes.

In the interim, insurers have agreed to extend the grace period for coverage of three categories of drugs eligible under the province’s Exceptional Access Program, if they are covered under a private plan. Insurers had originally agreed to provide coverage for these drugs for a transition period that was scheduled to end June 30, 2018 to help children and youth experience a smooth transition to OHIP+.

The three categories of drugs include:

  • Antibiotics and anti-infectives, including antiviral and antifungal agents;

  • Blood thinners; and

  • Drugs with low Exceptional Access Program approval rates.

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