OHIP+: What Family Physicians Need to Know

October 31, 2017

Effective January 1, 2018, children and youth in Ontario will be able to get their prescription medications for free. Coverage will be automatic, with no upfront costs. Here are answers to some common questions for family doctors about the new OHIP+ program.

prescription pad

1. Who and what medications are covered through OHIP+

  • All children and youth aged 24 and younger who have OHIP coverage will automatically be enrolled in OHIP+. The new program will cover all drugs currently reimbursed through the Ontario Drug Benefit (ODB) program. This includes more than 4,400 drug products listed on the ODB Formulary/Comparative Drug Index and additional drugs eligible for funding through the Exceptional Access Program (EAP). There will be no out of pocket costs (i.e. deductibles or co-payments).
  • Starting January 1, 2018, if a child or youth aged 24 or younger requires an eligible medication, they or their caregiver can simply bring their valid prescription and health card number to a pharmacy and will receive that medication at no cost. No other information is required.

2. My patient is happy with her family’s private insurance plan. Can her children continue to be covered through their private insurance plan or must they transition to OHIP+?

  • All Ontarians ages 0-24 who have OHIP coverage will automatically be covered under OHIP+. The ODB program will become 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.

3. If it turns out my patient requires a medication not covered through OHIP+, how do I ensure they continue to have coverage for that medication?

  • 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 under 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. For instance, for children and youth currently receiving a medication through a private insurer that may be covered through the EAP program, physicians should apply through the EAP program to determine coverage. The Ministry of Health and Long-Term Care is encouraging submissions for eligible patients as soon as possible by faxing full EAP requests to: 1-844-227-6590. This fax number is different from the one noted on the current Request for an Unlisted Drug Product form. Faxing requests for OHIP+ eligible recipients to this new fax number will help ensure that these are assessed prior to January 1, 2018.
  • There is also a streamlined EAP form available for OHIP+ eligible patients who are already stable on certain medications. The form is available on the Government of Ontario’s Central Forms Repository website by searching “OHIP+ EAP”. 
  • OHIP+ will be complemented by the new ‘Special Authorization Digital Information Exchange’ (SADIE), which will support electronic review and approval of drugs within the EAP. Specific details regarding this new EAP electronic approval process will soon be available online. 

4. I have a 12-year-old First Nations child in my practice. Is he still considered insured through NIHB or is he now covered through OHIP+?

  • First Nations children/youth will have a choice between using NIHB and OHIP+.  If a child/youth is OHIP insured and also eligible for benefits through NIHB, the family/youth may choose to claim their eligible drug benefits through either program.
  • One of the differences between OHIP+ and NIHB is that OHIP+ covers medications listed on the ODB formulary (many of which are only available with a prescription), whereas NIHB covers both many prescription medications and also over-the-counter medications like diphenhydramine.  

5. I have a child in my practice who is already receiving drug benefits through ODB. How will OHIP+ impact that coverage?

  • Children and youth already enrolled in the ODB program will continue to have access to the same medications for which they are already covered. The benefit of OHIP+ is that it eliminates any upfront costs such as co-payments and/or an annual deductible. These changes will be automatic – there is no need to contact the ODB to initiate this change.

 

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