OHIP+ Children and Youth Pharmacare

December 21, 2017

Under OHIP+ Children and Youth Pharmacare, OHIP-insured children and youth aged 24 years and under in Ontario will be able to get their prescription medications at no cost when they visit an Ontario pharmacy. Enrollment will be automatic, with no costs (i.e. no co-payment and no deductible). Here's what family physicians need to know and steps to take before January 1 to avoid gaps in their patients' coverage.

1) Complete Exceptional Access Program Requests before January 1, 2018

  • Under OHIP+, eligible drugs includes all drugs currently covered through the ODB Forumlary.
  • OHIP+ also covers other drugs through the Exceptional Access Program (EAP) under specific clinical circumstances. To access medications through the EAP, you must submit a request to the Ministry on your patient's behalf - see below for details.

2) OHIP+ and Private Insurance Coverage

  • Children and youth aged 24 years and under who have OHIP insurance will automatically be enrolled in the ODB program through OHIP+. The ODB program will be the first payer.
  • If the drug in question is not currently funded through the ODB Formulary or the EAP, it will not be funded through OHIP+. Family physicians can speak with patients/families about alternative medications that may be covered; or the drug may be covered by a third party, such as private insurance.
  • Physicians and patients can use an online search tool to see if a medication is covered.

3) Streamlined and Full EAP Forms – Which Forms to Use

  • Family physicians are encouraged to speak to patients and families prior to January 1, 2018 to discuss current prescriptions and OHIP+.
  • Children and youth with an approved EAP request will be fully covered for the cost of their medications through OHIP+.
  • Children and youth who have not had a previous EAP assessment will need an EAP assessment to determine if they will receive coverage for an EAP product, including medications currently received through a private insurer. 
  • A streamlined EAP form is available for OHIP+ eligible patients who are already stable on certain medications. Go to the Government of Ontario’s Central Forms Repository website and search “OHIP+ EAP”. 
  • If the medication being requested is not listed on the streamlined EAP form, physicians may use the standard EAP request form that can be accessed from the streamlined form by selecting "other" in the drop-down menu. Additional information as required may be added to the standard request application.
  • The OHIP+ team has been working with private insurers to help ensure there are no gaps in coverage. For an interim period - from January 1 to June 30, 2018 - private insurers will continue to cover certain types of EAP drugs:
    • Antibiotics (and anti-infectives, including antiviral and antifungal agents)
    • Blood thinners (low molecular weight heparins)
    • Drugs with low EAP approval rates 

EAP RESOURCES

Contact EAP

E-mail:    EAPFeedback.MOH@ontario.ca 
Phone:   416-327-8109 or 1-866-811-9893
Fax:        1-844-227-6590

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