Ontario’s OHIP + program took effect earlier this year, providing government paid prescription drug coverage for individuals 24 and under for medicines listed in the Ontario Drug Benefit Formulary as well as eligible Exceptional Access Program (EAP) drugs.
The EAP, a part of OHIP+, allows for access to and payment for drugs that aren’t funded through the Ontario Drug Benefit (ODB) formulary, if no listed alternative is available. If an individual’s prescription drug is not a part of the ODB formulary and is denied through the EAP, only then would they submit a claim to their private drug plan, including their EAP rejection letter.
As part of the transition to OHIP+, private insurers have been assisting with coverage for some prescriptions that may be considered under the EAP without the required EAP rejection letter if these prescriptions were previously paid under the individual’s group plan prior to OHIP+. A decision agreed upon to help the government with a backlog of EAP decisions and approvals. However, beginning July 1, 2018 private insurers will require patients to be assessed and denied funding through the EAP for these drugs before they will consider accepting any claims.
What you need to know:
If the individual has not already had an EAP assessment, they will need one to determine if they will receive coverage for the EAP drug under OHIP+.
An individual will also need to submit a funding request through their doctor.
The process of receiving EAP approval can take up to six weeks, depending on the medical circumstances.
Find more information on OHIP+ and the EAP here.