Universal drug program in Ontario: Update

Last May, we informed you that Ontario would offer a free universal drug program, OHIP+, to children and youth under the age of 25. This plan will officially come into force on January 1, 2018.

As a reminder, here are the key features of this new universal program:

• Coverage for Ontarians under the age of 25, regardless of their current coverage or the availability of private coverage
• Coverage for over 4,400 drugs, which is the same coverage offered under the Ontario Drug Benefit (ODB) Program
• First payer
• No deductible
• No co-payment
• No annual premium

In addition, OHIP+ will cover drugs listed under the Exceptional Access Program, which will provide access to many expensive drugs, including drugs used to treat rheumatoid arthritis, cancer and some rare diseases.

Starting January 1, all eligible Ontarians will simply have to show their Ontario Health Card to benefit from this plan.

Pharmacists will be required to submit a payment claim to OHIP+ before turning to a private plan. At that time, most insurers will be ready to coordinate benefits with the public plan.

Participants who currently use drugs covered by the Exceptional Access Program or Limited Use drugs covered by a private plan will receive a memo from their insurer asking them to have their drugs approved by OHIP+. For these drugs, depending on your insurer, benefits coordination may not be ready as of January 1. We encourage you to ask your insurer for their specific plan of action in this matter.

In our last bulletin on this topic, we proposed a three-pronged reflection process for private plan sponsors, which is still relevant today.

Group benefits plan premiums for Ontarians need to be reviewed. National organizations should therefore examine the need to establish separate pricing for their Ontario members. They should quickly check with their insurer to find out whether their administrative and contractual structure allows for such an adjustment. At the very least, plans with a major share of participants in Ontario should take this new parameter into account for their pricing as at January 1, 2018.

Organizations should reflect upon the definition of eligibility of dependent children, taking into account distinct provincial particularities. Most group benefits plans in Canada currently allow students to remain insured if they are under the age of 26. Ontario’s new program will cover only youth under the age of 25.

Many private plans cover a list of drugs that is more generous than the ODB list. Organizations should determine whether they want to continue to offer this expanded list and act as the first payer for drugs not covered by OHIP+.

This new program will bring about a number of changes. Reflection is therefore necessary, as well as a possible review of certain private group benefits plan parameters.

Normandin Beaudry specialists can offer you guidance on the impacts for your organization.