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Ontario government to end OHIP+ drug coverage for young people with private drug plans

On January 2, 2019, the Ontario government released a regulatory notice and a draft regulation that will make OHIP+ drug coverage only available to Ontarians under the age of 25 who do not have drug coverage through a private drug benefit plan. The changes will take effect in March 2019. Young people without private drug benefit coverage will continue to have OHIP+ coverage, which grants access to the approximately 4,400 drugs included in the Ontario Drug Benefit Formulary. The OHIP+ youth pharmacare initiative was introduced by the previous Ontario government effective January 1, 2018. The new Ontario government had previously announced its intention to amend the program in June 2018. The announcement was summarized in the August 2018 News & Views.

Definition of private drug plan

The draft regulation defines a private drug plan broadly as “an employer, group or individual plan, program or account, however described, that could provide coverage for, including the provision of funding that could be used to pay for, any drug product,” regardless of whether:

  • the private insurance plan covers the particular drug for which coverage is sought;
  • the child or youth or another person captured under the private insurance plan is required to pay a co-payment, deductible, or premium; or
  • the child or youth has reached their annual maximum under the private insurance plan and no further coverage is available.

Individuals or families with private insurance that encounter significant out-of-pocket costs will once again be able to apply for additional financial support through the Trillium Drug Program. This was the case prior to the implementation of OHIP+ on January 1, 2018.


Comment

The impact of the change will vary from plan to plan, but employers and other drug plan sponsors should know that any cost savings they may have realized under the original OHIP+ youth pharmacare program will likely be negated.

The proposed regulations raise a number of questions. It is not clear how pharmacists and the government are to confirm whether young people have private insurance and how the transition will occur in March 2019. Some forms of indirect private drug coverage, such as a health care savings account, may raise interpretation questions. Finally, it is also open to question whether plan sponsors will be allowed to purposely exclude drug coverage for Ontario-resident youth under age 25 so that they can rely on the public OHIP+ program instead.


News & Views - February 2019 (PDF)