OHIP Changes – April 1, 2019

Amendment to Ontario Regulation 201/96 made under the Ontario Drug Benefit Act to make changes to Ontario Drug Benefit Program coverage for children and youth aged 24 years and under (OHIP+) February 27, 2019

Further to recent announcements, the government is changing OHIP+ by focusing benefits on those without private plans. The changes come into effect on April 1, 2019.

People who are affected

The changes affect OHIP-insured children and youth 24 years of age and under as follows:

Those who do not have a private plan

Those who do not have a private plan will remain eligible for the Ontario Drug Benefit program through the OHIP+ eligibility stream, and continue to receive benefits from the Ontario Drug Benefit program without co-payments or deductibles.

Those with a private plan

Will access prescribed medicines as they did prior to the launch of OHIP+ through their private plan

Individuals or families who have significant out-of-pocket costs, despite having a private plan, could apply for additional financial support through the Trillium Drug Program

  • The Trillium Drug Program is available to all OHIP-insured Ontarians who have high prescription drug costs compared to their household income. To find out more about the Trillium Drug Program please visit: https://www.ontario.ca/page/get-help-high-prescription-drug-costs
  • Where the out-of-pocket costs meet the Trillium Drug Program deductible threshold, public coverage would be provided under existing program requirements.
  • Where the out-of-pocket costs do not reach the Trillium Drug Program deductible threshold, no public coverage would be provided (unless the Ministry of Health and Long-Term Care Drug and Devices Division 2 child/youth becomes eligible through another eligibility stream, such as social assistance, home care recipient, etc.).

Children and youth, with or without a private plan, who are eligible for the Ontario Drug Benefit Program through social assistance, their receipt of home care services, or their residence in a long-term care home, home for special care or community home for opportunity will have no copayments or deductibles.

Definitions

“Private plan” is defined to mean an employer, group or individual plan, program or account, however described, that could provide coverage for drug products, including the provision of funding that could be used to pay for drug products, regardless of whether:

  • the private plan covers the particular drug for which coverage is sought,
  • the child or youth or another person captured under the private plan is required to pay a co-payment, deductible, or premium, or,
  • the child or youth has reached their annual maximum under the private plan and no further coverage is available.

This approach recognizes the important contribution of private insurers and employers in the provision of health benefits to Ontarians. A housekeeping amendment was also made to Ontario Regulation 201/96 to remove a reference to the Ontario basic income pilot that will end on March 31, 2019. This change also comes into effect on April 1, 2019.

Additional Information

For pharmacies:

Please call ODB Pharmacy Help Desk at: 1-800-668-6641For all other Health Care Providers and the Public:

Please call ServiceOntario, Infoline at 1-866-532-3161 TTY 1-800-387-5559. In Toronto, TTY 416-327-4282.