In January 2018, the previous Ontario Liberal government launched OHIP+ Youth Drug program, with an estimated annual cost of $465 million. It was designed to provide coverage to all OHIP-insured dependents under the age of 25 for the roughly 4,400 drugs currently paid for by the provincial Ontario Drug Benefit program. The new Conservative Ontario government took office in June 2018 and announced they would be reviewing the OHIP+ program. In February 2019, they announced they would be making changes to OHIP+ in an effort to reduce the cost to government and tax payers. The actual cost for this program had reached almost a billion dollars per year and rising. These changes may affect some of your employees, their spouses and children.

The draft regulations introduce an “either or” approach, which restricts the free prescription drug coverage program to dependents under age 25 who are not covered by private plans. It further defines a private plan as any type of employer, group or individual plan, program or account that could (potentially) provide coverage for any drug product at all.

What’s changing?

Effective April 1, 2019 OHIP+ will no longer cover individuals 24 years old and under with drug coverage through a private insurance plan, such as a company group benefits plan.

  • With prescription drug coverage through a private plan/group program, drug claims must be submitted to that plan.
  • Without prescription drug coverage through a private plan/group program, drug claims can continue to be submitted to OHIP+ for consideration.

What does this mean to your employees?

Individuals who have any coverage at all under any type of private plan must look solely to the private plan for coverage whether or not the plan fully covers the cost of the drug, whether or not maximum limits have been reached under the plan, and whether or not the plan covers the particular drug at all.

What your members need to do

Starting April 1, 2019, when you, your spouse, or your children obtain a prescription drug, let your pharmacist know you’re not covered under OHIP+ anymore. They can submit the claim to your group benefit plan.

What the Ontario Ministry of Health has done

The Ministry has sent a letter to individuals 24 years old and under who may be taking a drug paid under the ODB list of drugs under the Exception Access Program (EAP). They’ve also sent letters to physicians who have patients 24 years old and under who have been approved for a drug through the EAP, advising them of the changes, and asking them to help patients who may require approval from their insurer for the specific drug.

Employees seeking further information including about covered medications, may refer to the Provincial government website below:

 Edited for content and revised from multiple sources including Benefits Canada eNews February 4, 2019 and various Insurer notices.

 The Leslie Group is a full services consulting firm committed to staying on top of relevant issues pertaining to benefit programs. Should you have questions, please contact your Employee Benefits Consultant at The Leslie Group Limited.