In January 2018, the Ontario government launched OHIP+, a provincial drug program that provides coverage for over 4,400 drugs for all Ontarians under 25. The program is changing. Effective April 1, 2019, OHIP+ will only be available to Ontarians under 25 without a private drug plan or a health spending account.
Here are the key details about the OHIP+ legislative change:
- People with private drug plans or health spending accounts will no longer be eligible for OHIP+.
- The Ontario government defines a private plan as a drug plan or a health spending account that provides coverage for a prescription drug claim.
- If the drug is not covered by a private drug plan, the member will not be eligible to claim the drug under OHIP+.
- People with high out-of-pocket prescription drug expenses will have the option to apply to the Trillium Drug Program.
- Pharmacists will be responsible for asking individuals if they have private drug insurance and submitting the claim accordingly.
We’re actively working with CLHIA on a process that will ensure a smooth transition for impacted individuals. We’ll communicate more details in the coming weeks.
Pricing changes at renewal
As a result of the change to OHIP+, we’ll update our system to ensure compliance with the legislation as plan members will need to rely upon your plan for prescription drug coverage for eligible Ontario children and youth under 25. We’ll also be adjusting the Extended Health Care (EHC) rates at renewal time to reflect the anticipated increase in claims due to the OHIP+ reversal. The adjustment factor varies based on the financial arrangement of the plan and the renewal effective date, as follows:
- Insured non-refund plans: The adjustment factor is based on the estimated impact to our Ontario block of business, then adjusted for each plan’s Ontario drug claims experience and pro-rated for the number of months OHIP+ was in effect during the most recent experience period. The rate impact will include a retroactive adjustment to cover the months from April 2019 to the renewal effective date.
- Insured refund plans: The adjustment factor will be client-specific, based on your plan’s experience before the introduction of OHIP+.
- Administrative Services Only (ASO) plans: increased claims will flow through the claims experience immediately for the invoice covering the months following March 2019.
If your plan is impacted, we’ll include an explanation about the OHIP+ adjustment in your renewal package.
Questions? We’re here to help.
For Clients with less than 50 employees, please contact your Client Service Administrator at 1-877-786-7227.
For Clients with more than 50 employees, please contact your Sun Life Group Benefits representative.