January 2, 2018

OHIP+

OHIP+ is a new health care initiative launched by the Ontario Government effective January 1st.  It is a publicly funded program that provides medication free of charge to Ontarians with a valid health card up to their 25th birthday.  The plan covers drugs listed under the Ontario Drug Benefit (ODB) formulary and those approved through the Exceptional Access Program (EAP).
 
The ODB covers approximately 4,400 drugs including those used to treat diabetes, ADHD, asthma and allergies, and some childhood cancers among many others.  However, some prescriptions require prior approval from the government before they are eligible.  These drugs are reviewed through the EAP.  Your medical practitioner will submit an application for these prescriptions on your behalf. 

Filling a Prescription

When filling a prescription for youth under age 25, present both their Ontario health card and your drug benefit card. If the prescription is not eligible for OHIP+, the pharmacist can submit it to your group plan. However, if it is an OHIP+ eligible expense, the claim must be paid through the OHIP+ program.  If the pharmacy submits it through your group plan, they will get a decline message that the claim is OHIP+ eligible and must be submitted through the Ontario health card. 
 
Individuals currently taking an EAP eligible drug must apply to the government for coverage.  This process may take several weeks.  Therefore, to ensure a smooth transition, your insurance company will continue to provide coverage until the government has issued their funding decision.  This transition period will run until June 30th.  After June 30th, all EAP-eligible prescriptions must be submitted to OHIP+, not the group plan.

Paying for a Prescription

OHIP+ eligible prescriptions are fully covered by the government – there is no deductible, no dispensing, and no co-insurance.  Non-OHIP+ eligible expenses will be paid as per the terms of your group plan.  If you have a drug card, you will only pay out-of-pocket what is not covered by the plan. 

Out of Province Students

Youth studying outside of Ontario may be eligible if they are still covered by OHIP and the prescription is filled at an Ontario pharmacy.  An extended amount of a prescription may be available. 

 
Frequently Asked Questions

Do I have to register for OHIP+
No.  All Ontario residents under age 25 with a valid health card are automatically enrolled in the program.
 
Do employees under age 25 have to enroll in the group plan?  Can they waive health care? 
Yes, employees should still be enrolled and cannot waive health care unless they have coverage through a spousal plan.  The group plan covers a much wider range of medications than the ODB (approximately 14,000 vs. 4,400).  It also provides other medical services such as medical devices and paramedical services.
 
Is my child still covered by my group plan?
Yes, providing your child continues to meet the definition of a child outlined in your benefit booklet.   Your group plan covers a much wider range of medications than the ODB (approximately 14,000 vs. 4,400).  It also provides other medical services such as medical devices and paramedical services. 
 
How do I know if a prescription is OHIP+ eligible?
Your pharmacist will know this information and will submit the claim accordingly.  However, you can look up prescriptions here:  https://www.ontario.ca/page/check-medication-coverage/
 
How do I submit an application to EAP?
Your medical practitioner will submit the application on your behalf. The government will issue you a funding decision letter. 
 
My family is covered under the Ontario Trillium Plan. How does OHIP+ impact that plan?
You will no longer have to pay for OHIP+ eligible expenses therefore they will not count towards satisfying your Trillium plan annual deductible.
 
 
More Information
 
 
Back to Benefits Bulletin

Benefits Bulletin

October 31, 2018 Cannabis in the Workplace

With the legalization of cannabis last month, there have been a lot of questions about how it impacts the workplace..

Read More View All Recent Posts

Health & Wellness

October 1, 2018 Marijuana Legalization

Marijuana, Cannabis, Mary-Jane, Weed, Ganja – call it what you like, it will all be legal in Canada on October.

Read More View All Recent Posts

GMS Quiz Corner

May 1, 2016

Thanks for playing!

Let us design a creative, sustainable benefit program for you

Get your free consultation