June 1, 2018

OHIP+ and the EAP: Transition Period is Ending

OHIP+ is the government-funded program that took effect January 1st.  It covers drugs for Ontario youth up to age 25.  Drugs covered under OHIP+ are not covered by the group plan. 

OHIP+ covers drugs listed on the Ontario Drug Benefit formulary (ODB).  This covers approximately 4,400 drugs.  It also covers drugs not covered by the ODB but eligible under the Exceptional Access Program (EAP).

The EAP provides funding for drugs not listed on the ODB and where no suitable substitution is available on the ODB.  Your doctor can check to see if the drug he/she is prescribing is an EAP eligible drug.  If so, they must submit an application on the patient’s behalf for coverage.  If the application is approved, the drug is covered by OHIP+. 

The EAP application process can take up to 6 weeks to process.  As such, when OHIP+ was first rolled out, the insurance companies agreed to continue to cover some drugs that were EAP eligible up to June 30th. 
 
Categories included in this transition period were:

  • Antibiotics and anti-infectives
  • Blood thinners
  • Drugs with low EAP approval rates

This transition period allowed families sufficient time to meet with their doctor and have an application submitted and returned while not having to bear the financial burden during the process. 
The transition period ends June 30th.  Therefore effective July 1st EAP-eligible drugs will not be covered by the group benefit plan. 

All those under age 25 taking a prescription that is covered by the group plan are encouraged to check with their doctor to confirm if the drug is an EAP-eligible drug.  If so, their doctor should submit an application right away.  If the application is approved, it will be covered in full by OHIP+.  If it is denied, there may be coverage available under your group plan with payments subject to the terms of your plan.

More information: www.ontario.ca/OHIPplus

 

Action Plan
Question Response Action
Am I or any of my dependents eligible for OHIP+ and taking a prescription in any of the 3 above-mentioned categories? No  None
Yes Talk to doctor to find out if drug is EAP eligible
Is the drug eligible for EAP? No  None
Yes  Have doctor submit application

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