FAQ: How does OHIP+ work?

By Teen Health Source

OHIP+ is a government program that aims to help cover medication costs for youth. It’s gone through some changes since it was introduced, which has caused some confusion on who it’s for and how it works. This post answers some of our more frequently asked questions about OHIP+. Please let us know if there’s still more you want to learn!

What does OHIP+ cover?

Regular OHIP covers many things, but one of the key things that it does not cover is “prescription drugs provided in non-hospital settings.” This would include prescriptions for things like birth control.

OHIP+ tries to fill this gap for youth by covering the cost of certain medications for people who are 24 years old and under and who do not have any type of private insurance coverage.

One thing to note is that not all drugs are covered by OHIP+. However, in many cases where a certain brand is not covered, a generic or no-name version is. If you know that you will be using OHIP+ to cover the costs of your medications, it might be worth telling your clinician of your plans so that they can prescribe a generic drug.

• See our blog post What is Covered by OHIP+: Birth Control Edition for more info.
• See what drugs are covered on the government’s website here: ontario.ca/page/check-medication-coverage You can also see what generic versions are of certain name-brand drugs, and see if those are covered.
• Full list of what OHIP does and doesn’t cover available here: ontario.ca/page/what-ohip-covers

What is Private Insurance?

Private insurance are plans that people can purchase to cover them for things in addition to what is covered generally by OHIP. Some ways that people have private insurance include:

• Someone purchased a plan. It’s not common for youth to buy their own insurance (as it’s expensive), but in general people can buy their own insurance coverage.
• It’s offered through school. Many colleges or universities offer their students access to some medical coverage plans. Students are generally automatically enrolled in their school’s insurance plan, but you can opt out. Many schools also offer UHIP, which is the University Health Insurance Plan for international students, employees and dependants.
• It’s offered through work. Some jobs offer their employees access to some medical coverage plans.
• It’s offered through someone else’s insurance plan. For example, your parents might have insurance that covers you.

With private insurance, you often have to pay upfront for a medication or service, and then submit a claim to the insurance company after the fact. Sometimes a pharmacy/clinic can bill the insurance company directly if you show an insurance card or if they already have that info on file from a previous purchase.

It is worth noting that if you are covered under someone else’s private insurance, they are likely able to see any coverage claims that are made towards that plan. So for example, your parents could see whatever medications you submitted for coverage if it is under their insurance plan. This can be a barrier for youth who do not want their parents know they are using any kind of birth control.

Getting Medication If You Qualify for OHIP+

Here’s how the government describes the process for people who do qualify for OHIP+:

1. Visit your doctor or nurse practitioner and get your prescription.
2. Take your health card OR health card number to any pharmacy in Ontario – you don’t need a separate or special card. Your pharmacist may ask if you are covered by a private plan.
3. If you do not have a private plan, the pharmacy will fill your prescription at no charge if it is on the approved list of covered medications.

There are no additional costs associated with getting your medication, and all information would stay confidential to you and your OHIP record.

For more information, please check out:

• Learn About OHIP+ on Ontario.ca
• FAQ: Can My Parents Access My Health Records? on Teen Health Source

Getting Medication If You Do Not Qualify for OHIP+

If you have any type of private insurance, you do not qualify for coverage under OHIP+. This does not affect your regular OHIP coverage.

Here’s how the process works if you do not qualify for OHIP+:

1. Visit your doctor or nurse practitioner and get your prescription.
2. Take your health card OR health card number to any pharmacy in Ontario.
3. Some people will have a card from their insurance provider they can use to pay for the medication. If you have visited the pharmacy before, they may have your insurance information already on file. Without those pieces of information, the pharmacy will not know if you have private insurance coverage or not.
4. Sometimes it is also possible to pay for your medications and submit a claim to your insurance provider, who will then reimburse you for the costs.

What if I accidentally tell the pharmacy that I don’t have insurance, but find out later that I do?

The government or the pharmacy don’t know you have coverage unless you tell them. If you forgot or were unaware that you had coverage, it’s unlikely that they would find out. In some cases the government may contact you to repay the cost of the medication, but this would not be what normally happens.

However, if you went to a pharmacy that had a record of you using insurance to cover prescriptions and of you using OHIP+, there’s a chance that your name could be highlighted in an audit as an irregularity. In this case, it is likely that you would be asked to clarify the status of your insurance and/or pay for any medications that were mistakenly charged to OHIP+. This generally would not result in a fine or any other legal consequences. If this was a regular pattern, then there could be a fraud investigation, but again, this is not what normally happens.

Insurance companies generally do not open up their records to the government unless they are assisting with an ongoing fraud investigation.

How often are pharmacies being audited?

Pharmacies are being audited at random, so it’s not a regular thing at all. The government would likely be looking for a number of different irregularities (not just OHIP+ stuff). So it’s not even a guarantee that the pharmacy you visit will be audited.

Please see the goverment’s page about OHIP+ if you have questions regarding things like the Trillium Health Benefit or if you’re enrolled in Ontario Works or the Ontario Drug Benefit Program: ontario.ca/page/learn-about-ohip-plus

If you have questions about this topic, feel free to contact one of our peer educators. [Link]

Last Updated: June 2020