The OHIP+ program, also known as Children and Youth Pharmacare program, was implemented on January 1, 2018 by the Province of Ontario to provide free prescription drug coverage for all children and youth 24 years of age or younger, regardless of family income or whether the child / youth is covered by private insurance. Under the current OHIP+ program, the province is always the first payor for eligible drug products, even if the child / youth is also covered by private insurance.
The new Ontario government said it would amend the OHIP+ program so the province would no longer always be first payor, but that the province would cover any remaining eligible costs not paid for by private insurance. However, with the Proposed Amendments to Ontario Regulation 201/96 made under the Ontario Drug Benefit Act (proposed to come into force in March 2019), only children / youth without private insurance will continue to receive coverage through OHIP+. For children / youth with private insurance (whether or not the insurance covers the particular drug in issue), not only will the province cease being the first payor, it will also not be the second payor. Instead, the province is proposing that such individuals rely on the Trillium Drug Program for financial support for any out-of-pocket costs (e.g. if the individual is responsible for co-payments under their private plan). Trillium is a program that helps families with high prescription drug costs relative to their household income. However, for out-of-pocket costs prior to the Trillium deductible being reached, no public coverage would be provided and the individual would be responsible for those costs.
These proposed changes, intended to be “cost-efficient”, could have some unintended consequences as they could, ironically, incent families and employers to choose drug insurance plans which do not cover children / youth.
Pharmaceutical companies with costly drugs which are included in the OHIP+ program should realize there may be more of a demand from Ontario residents for financial support from patient support programs (e.g. to help with costly co-payments) if the proposed changes go forward and should plan accordingly.