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OHIP+ Children and Youth Pharmacare Launches Jan 1, 2018
Jan 2nd, 2018
In April and August of this year, you received communications from our Selectpath team outlining the highlights of the OHIP+ Children and Youth Pharmacare program effective January 1, 2018.
As the launch date is quickly approaching, we have included below a brief additional update, as well as a Draft Employee Communication you are welcome to use.
Draft Employee Communication - please see the following link.
Recap - Highlights of OHIP+
• Effective January 1, 2018
• All Ontarians age 24 or under who have OHIP coverage will be automatically covered
• OHIP+ is not tied to income levels, meaning all Ontario families are eligible, and there are no copayments, deductibles, or dispensing fee charges
• OHIP+ is the first-payer, prior to private / group insurance plans
• Uses the same Ontario Drug Benefit formulary as currently available to seniors, covering 4,400 medications, though will not cover Out-of-Province or Out-of-Country drug claims
• The pharmacy community is ready to submit OHIP+ claims to the government, with just a valid prescription and health card number required from the individual
• For the majority of individuals age 24 or under, the process will be seamless (see Exceptional Access Program (EAP)-eligible member notes below)
Who is covered?
All Ontarians age 24 or under who have OHIP coverage, regardless of income, family and student status will automatically qualify for OHIP+ coverage. No application is needed to enrol in the program and OHIP+ coverage will end on the 25th birthday of the claimant. OHIP+ claims will be submitted by the pharmacy and will be adjudicated online using the OHIP Health card.
What is covered?
OHIP+ will give Ontario children and youth access to more than 4,400 drugs reimbursed under the Ontario Drug Benefit (ODB) Program, including the three primary categories of drugs below:
• ODB general formulary - Full coverage.
• ODB Limited Use - Full coverage for claimants who meet pre-defined medical criteria. Eligibility for coverage is determined by the prescribing physician at the time when the prescription is written.
• ODB Exceptional Access Program (EAP) - Includes the majority of high cost drugs and requires a doctor to initiate the request by completing an EAP form. The Ontario Ministry of Health evaluates each EAP request on a case-by-case basis.
o Specifically, for drugs available through EAP, an individual eligible for OHIP+ must submit a request for EAP funding.
o Recognizing EAP decisions can take time, a transition strategy has been agreed upon for a number of specific drugs (anti-infectives, blood thinners, drugs with low EAP approval rates). While these drugs could be considered EAP-eligible immediately, they may continue to be covered by private plans from January 1, 2018 - June 30, 2018, without an EAP denial letter.
o The province recommends individuals speak with their doctor to see if an ongoing drug is eligible for EAP funding. Many insurers are notifying individuals taking EAP-eligible drugs, advising them to speak to their doctor/prescriber about submitting a funding request to EAP as soon as possible.
o If the drug is denied by EAP, the drug may continue to be covered under the private plan, depending on the in-force plan design and the carrier's Specialty Authorization process.
How does OHIP+ impact your Group Benefits plan coverage?
There is no action that you need to take with the introduction of this program, as the changes are applied automatically. While OHIP+ will be the first-payer for more than 4,400 ODB eligible drugs for Ontario children and youth age 24 or under, there are over 14,000 drugs covered under a typical Benefits program along with a wide variety of other expenses. Drugs eligible under your Group Benefits plan but not covered by OHIP+, as well as any other eligible Health and Dental expenses, will continue to be reimbursed normally by your Group Benefits plan for individuals eligible for OHIP+.
Financial Impact to your Group Benefits program
We have continued to estimate Drug paid claims savings ranging from -1% to -5%, with average of -3%. In some cases, savings will be higher than this range depending on high-cost EAP-eligible drugs and age composition of your group. The savings impact will depend on your funding arrangement as follows:
Fully-Insured plans - insurers are generally reviewing the impact of OHIP+ as part of the next renewal, either through claims experience or an OHIP+ reduction factor. A small number of insurers are decreasing rates January 1st to reflect this plan impact (ex. Manulife, who has or will be notifying you shortly).
Administrative Services Only (ASO) and Refund plans - the savings will flow through the plan to the financial surplus results, securing the full savings.
Other Resources
OHIP+ Website www.ontario.ca/OHIPplus
OHIP+ INFOline 1-866-532-3161
OHIP+ Drug Coverage Questions: 1-866-811-9893 (toll-free)
OHIP+ Coverage Drug Lookup Tool: https://www.ontario.ca/page/check-medication-cover...
EAP Request Form: health.gov.on.ca/en/pro/programs/drugs/eap_mn.aspx#3
Questions?
Contact your Selectpath Benefits and Financial Inc. group benefits representative.