More Details about OHIP+ Transition

Effective April 1, 2019, only children and youth under the age of 25 who are not covered by a private benefits plan will qualify to receive eligible prescriptions at no cost through OHIP+. Those with private health coverage (and not otherwise eligible for the Ontario Drug Benefit program) must submit prescription drug claims through their private plans.

The new rules apply to children or youth with any source of private coverage, including healthcare spending accounts, individual plans or student plans. Even if the patient’s drug is not covered under their private plan, they will not be eligible for OHIP+. Individuals with coverage through a private plan may apply to the Trillium Drug Program for additional out-of-pocket costs (for eligible prescription medications) that create a significant financial burden.

How are plan members affected by this transition?

The impact of the changes on plan members and their dependents will vary, depending on the coverage provided by their private plan and the drug they are prescribed.

For example: If their private plan includes a deductible or co-insurance, or if the drug isn’t covered under their private plan, plan members may incur out-of-pocket expenses that they didn’t experience when they were covered under OHIP+

As well, if a plan member or their dependent was prescribed a drug included on Equitable Life’s Speciality Drug Management Program (SDMP), they may be required to obtain prior authorization before the drug is eligible for coverage under their Equitable Life plan.

Minimize disruptions in specialty drug coverage!

If the plan member has not previously obtained prior authorization from Equitable Life, they should contact Equitable Life’s Customer Service Department, they’ll be able to guide them through the prior authorization process. Equitable Life will work with plan members through the OHIP+ transition process, to minimize disruptions in specialty drug coverage.

If the plan member had previously received prior authorization from Equitable Life, no action is required – the specialty drug medication will be adjudicated by Equitable Life, as per the current parameters of the drug plan.

If the plan member had previously received prior authorization from Equitable Life, no action is required – the specialty drug medication will be adjudicated by Equitable Life, as per the current parameters of the drug plan. Plan members can refer to the list of drugs included in the SDMP program.

If the plan member has not previously obtained prior authorization from Equitable Life, they should contact our Customer Service Department, who will guide them through the prior authorization process. Equitable Life will work with plan members through the OHIP+ transition process, to minimize disruptions in specialty drug coverage.

Source: https://www.equitable.ca/