News and Updates


OHIP+ and Exceptional Access Program


January 18, 2018

On January 1, 2018, the Ontario Ministry of Health and Long-Term Care (MOHLTC) introduced OHIP+: Children and Youth Pharmacare. Ontario residents who are 24-years-old or younger will be able to get their prescription medications for free under the new OHIP+ program. Enrolment and drug coverage will be automatic, with no upfront costs such as co-payments or deductibles.

The new program will cover all drugs currently reimbursed through the Ontario Drug Benefit (ODB) program. This includes more than 4,400 drug products listed on the ODB Formulary/Comparative Drug Index and additional drugs eligible for funding through the Exceptional Access Program (EAP) provided by the Ontario Ministry of Health and Long-Term Care. Therefore, medication that may be considered for funding through the EAP will not be covered under your employee benefits plan or RTIP/ARM health insurance plan (if applicable), unless you take the following steps:

Speak with your prescribing doctor/nurse practitioner to:

  1. Ask if there is a suitable alternative drug covered on the Ontario Drug Benefit Formulary that can be prescribed instead of the EAP drug.

Or,

  1. Request that they complete an EAP application for coverage for the EAP drug. The approval process can take a few weeks. Please take action now, so you are not paying out-of-pocket the next time you get the prescription filled.

Important notes:

  • At the beginning of January, a notice was sent out from the insurer (Manulife Financial) and OTIP to members who are currently using EAP drugs, to give them sufficient time to apply for EAP funding.
  • If applicable, your EAP drug claims will be covered under your health plan until either March 1 or April 1 (effective date) , depending on the plan you are covered under. After your effective date, you will need to follow the steps above and below.
For non-Prior Authorization drugs For Prior Authorization drugs

If EAP drug coverage is approved:

  • The doctor/nurse practitioner may contact you or you can call the doctor/nurse practitioner directly to find out the status.
  • Please inform your pharmacist the prescription will be paid through OHIP+.
  • You do not need to notify OTIP.

If EAP drug coverage is approved or denied:

  • The doctor/nurse practitioner may contact you or you can call the doctor/nurse practitioner directly to find out the status.
  • OTIP will require proof that the EAP application was approved or denied.
  • Please send this information to OTIP.
  • Once OTIP has been informed, the pharmacist can submit the EAP claim to see if it can be covered under the group benefits plan.

If EAP drug coverage is denied:

  • The doctor/nurse practitioner may contact you or you can call the doctor/nurse practitioner directly to find out the status.
  • OTIP will require proof that the EAP application was denied.
  • Please send this information to OTIP.
  • Once OTIP has been informed, the pharmacist can submit the EAP drug claim to see if it can be covered under the group benefits plan.

 

Send this information to OTIP:

By mail:

OTIP Health Claims
PO Box 280
Waterloo ON N2J 4A4

Please include:

  • The patient’s name
  • Your plan number and OTIP ID number (can be found on your benefits card)
  • A copy of the notice from the province
By fax: 

Fax: 1-844-595-9551

Please add a cover page stating:

  • The patient’s name
  • Your plan number and OTIP ID number

Fax the cover page with a copy of the notice from the province.

Once OTIP has received your information, your records will be updated accordingly.

 

Questions? Please call OTIP Benefits Services at 1-866-783-6847. If you have questions about OHIP+, please visit www.ontario.ca/ohipplus.

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