On January 1, the new OHIP+: Children and Youth Pharmacare program for will go into effect for all Ontario residents under the age of 25 who have an Ontario health card number and an eligible prescription.
While OHIP+ represents a big step in a movement focused on bringing Pharmacare to everyone in the country, the plan does have some key limitations that Advisors should know about before advising their clients.
What is the OHIP+: Children and Youth Pharmacare program?
This program will cover eligible prescription drugs for young people under the age of 25, with no strings attached: no co-pay, no deductible, no dispensing fee, and no inquiries about how much the young person (or family) earns per year.
Coverage is automatic, and there is no need to enrol or register. Effective January 1, 2018 the youth, or a parent, can simply take an eligible prescription to an Ontario pharmacy along with his or her health card or health card number. The pharmacy will then fill the prescription at no charge.
The program is intended to relieve Ontario residents and their benefits plans from paying for these drug claims, which currently represent 13% of all claims. While the plan will cover 4,400 drugs in the Ontario drug benefit formulary, it will not include all prescriptions (particularly the more expensive drugs). Officials have warned not to assume that all requests will be approved; it is important to advise clients and plan members to check covered medications online. This also means that Ontario clients will likely see a much lower reduction in claims as opposed to the full 13%, based on an analysis of the covered drugs.
How does it affect other coverage?
Insurance Plans
OHIP+ will become the first payor for eligible drugs. Any unpaid portions not covered by OHIP+ may still be eligible for coverage under a private health insurance plan, subject to the terms of the private plan. And since OHIP+ only applies to the youngest Canadians, it does not replace the need for a comprehensive health plan.
Trillium Drug Program members
If an eligible child is a member of a Trillium Drug Program household, since the OHIP+ program is the first payor for eligible drugs, there are no out-of-pocket payments for OHIP+ claims. Any prescriptions paid by OHIP+ will not count toward the family’s annual deductible.
Students going to university/college in another province
If an eligible child attends university or college in another province, their prescriptions can still be covered through OHIP+ if they:
- remain insured by OHIP;
- have a valid prescription;
- get their medications filled at a pharmacy in Ontario.
They may also be able to receive a larger “travel supply” of medications before leaving Ontario.
How will this affect Benecaid clients?
Benecaid prioritizes a proactive approach to drug management and is dedicated to providing cost-effective solutions for your clients. Our underwriting team has reviewed the OHIP+ program in detail and the anticipated impact it will have on drug claims. Effective January 1, 2018, Benecaid will be applying an OHIP+ factor to projected claims for Benecaid flexStyle, flexFIT and Honeybee group renewals. For more information on the impact for a specific client please contact your Benecaid Account Manager.
How will this affect pricing for new quotes?
Benecaid has adjusted new Ontario group quotes to account for lower projected claims where warranted based on group demographics to reflect the impact of OHIP+.
Benecaid will continue to follow changes to the OHIP+ program and keep you informed. For more information on the OHIP+ program, please contact your Benecaid Benefits Consultant by email at advisors@benecaid.com or visit the Ontario Government website – www.ontario.ca/page/learn-about-ohip-plus.
