Update: Ontario amends OHIP+ drug program for children and youth
Effective April 1, 2019, Ontario has made benefit coverage changes to the Ontario Drug Benefit (ODB) program for children and youth aged 24 years and under. The changes to OHIP+ affect children and youth with private prescription drug coverage. A previous announcement of this change was discussed in the February 2019 News & Views.
Changes affecting children and youth with private plan coverage
Children and youth aged 24 years and under that do not have private plan coverage will remain eligible for the ODB program through the OHIP+ eligibility stream and will continue to be automatically covered by OHIP+.
Children and youth aged 24 years and under that have private plan coverage are no longer eligible for OHIP+.
A “private plan” is defined to mean an employer, group or individual plan, program or account that could provide coverage for drug products. This includes the provision of funding that could be used to pay for drug products, 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.
A Health Spending Account that provides access to drug coverage will qualify as a private plan, resulting in no access to OHIP+.
Children or youth with private plan coverage may still be eligible for other forms of financial support towards prescription drug coverage, such as the Trillium Drug Program.
These changes partially retract the OHIP+ program introduced by the previous Ontario government in January 2018. Prior to these most recent amendments, more than 4,400 prescription drugs were free of cost to children and youth under the age of 25, irrespective of whether they were covered under a private prescription drug plan. These costs will once again be placed on Ontario employers and employees who pay for the cost of private drug coverage.
Furthermore, families may face increased out of pocket expenses as well as other private plan limits on coverage for children and youth under the age of 25. At the same time, it should be noted that the ODB does not cover all of the drugs that are covered under private plans.