OHIP Coverage under 25 Years (For Medicines) — Answers For All Your Questions

Que. 1 & 2: What if I want to get covered by OHIP only because they pay 100% and my plan only pays 70–80% ? AND

Que. 2: What if I have private insurance on my profile at my pharmacy but I want to get covered under OHIP as I have to pay deductible/co-payment to my insurance ?

If you already have your plan on your profile at pharmacy, you CAN NOT bypass your private insurance and just get medications billed to OHIP. If you have your deductible/co-payment, you MUST need to satisfy it first. By any chance, if you escape it one time, still it will remain pending for next time and accumulate eventually !

Alternatively, parents can take their child off from their own benefits to get it covered by OHIP (depends on the services covered under OHIP) if they wish to do so. Survey result reflects that most parents don’t do that though as they don’t want to take a chance if something is not covered under OHIP.

If you DON’T have your private plan on your profile at pharmacy, choice is yours.

Que. 3 & 6: What if I have private insurance but I don’t present it to the pharmacy, so they can bill to OHIP ? Isn’t it easy to do so ? AND

Que. 6: What if I always have private insurance and I never inform to pharmacy and they keep billing to OHIP ? Is it fraud ? If something happens and I get caught, who is going to be liable ?

If you don’t present your private insurance to the pharmacy eventhough you have it, then its ethical violation. There can be two scenarios in this situation — 1) If the Pharmacist don’t ask “Are you covered under any private insurance?” then Pharmacist is liable.

— 2) If the Pharmacist ask “Are you covered under any private insurance?” and if you deny to have it, then Patient is liable. Depending upon this verbal conversation, pharmacist has to put an intervention code in the system to reflect “No private insurance — attestation” to maintain legality and to be compliant with OHIP rules and regulation. Many times pharmacist may ask to sign on prescription or small paper as an indication that patient do not have any private insurance.

So, once you do attestation (written or verbal), pharmacist is out of any conflicting situation. Now its solely upto the patient.

Ques. 4: What if I have private insurance but my insurance doesn’t pay for the medication(s), can pharmacy bill to OHIP ?

Please refer to the below link for OHIP+ guideline Question 6 of FAQ -

http://www.health.gov.on.ca/en/pro/programs/drugs/opdp_eo/notices/fq_pat_exec_office_20190311.pdf

Que. 5: What if I have 2 medications on my prescription, one is covered under private insurance and one is only covered under OHIP ? What shall I do ? Shall I inform the pharmacists if I have private insurance ?

Please refer the answer for Question 1 and 2 first. ! In addition to that, you need to know — Which one is covered under OHIP and which one under private insurance ? How expensive those medications are ? How long you will have your private insurance ? What is your deductible/co-pay ? Is the medication is for acute illness or chronic illness ? How far is the patient age for becoming 25 years old ?

Depending upon all these questions, its the patient who needs to decide what they have to do ! Some patients also prefer to get price quote only if the prescription is really expensive one and they will decide then after.

Que. 7: What if I don’t have private insurance and my Doctor gives me Brand Name Card for any medicine, can pharmacy bill OHIP and brand card both ? Isn’t it a kind of private insurance ?

Yes you can use both. It’s a promotional card from the manufacturer to keep their brand medication moving in market. It is not considered as private insurance. So, you can use with OHIP and get the brand name medication at equivalent price rate of generic medication.

Que. 8: My pharmacy wants me to sign/to do attestation that I don’t have private insurance before they bill to OHIP, shall I do that or I can deny it ? Is it a legal requirement to do so?

Its a good practice to have the signed paper on your file. Pharmacist mostly do that to have safe practice for any audit purposes. Some pharmacies have their softwares designed in a manner that they just need to have verbal consent and they can print the attestation on paper saying it has been done verbally.

Till date, its not a real legal requirement to do sign on paper physically. But once you do that, it gives confidence to the pharmacist to fill prescription without thinking about any conflict. But yes, if you don’t want to sign, its upto you and then pharmacist can decide upon his confidence level.

Que. 9: What if my private insurance stops covering suddenly because of temporary work closure and its going to reactivate again soon, can I use my OHIP meanwhile to cover my medications?

Yes you can do that. The bottmeline is, not to have any private insurance when you fill the prescription under OHIP. Pharmacist may document that if they wish to do so.

Que. 10: In general, is it good to be on private insurance or under OHIP ? Which one covers more ?

OHIP doesn’t cover some services like Dental, Eye examination more than once in a year, Vit. D level testing, some lab testings, etc. Under 25 years, if you don’t have private insurance, OHIP covers >4000 different types of medication at 100%.

Private insurance may cover upto 70 to 100% depending upon your plan but they may cover in full amount for other services. But, don’t forget, you may loose it once you left your work.

So, its not Black and White situation to decide which one is more preferable. It’s upto you to decide depending upon health conditions of yours and your enrolled dependents.

Que. 11: Whats the exact age for the coverage, is it under 25 or until I become 25 or until last day before I turned 26 years ?

According to OHIP+Guideline, Children and youth 24 years of age and under who are OHIP-insured, but who do not have a private plan, will continue to receive coverage for eligible prescription medications through OHIP+.

http://www.health.gov.on.ca/en/pro/programs/drugs/opdp_eo/notices/fq_pha_exec_office_20190311.pdf

Que. 12: Can I use different pharmacies ? In one of them I can use my OHIP and in other one I can use my private insurance. Is there any chances that I will be caught ? Are the pharmacists are allowed to verify anywhere ? How will they know if I am using two pharmacies ?

Its not ideal practice to do so. But, if you want to do that, then YES you can (restriction applies). In some occasions there are chances that it will reflect on pharmacy screen as “Duplicate pharmacy or Prior Drug claim exists”. It mostly happens during filling up narcotic prescription as its monitored with healthcard number.

Moreover, Pharmacists are allowed to verify any prescription related issues in a circle of healthcare professionals, if they feel anything suspicious.

Que. 13: Is there any exceptional circumstances if I can use OHIP eventhough having and knowing that I have private insurance ?

None of the exceptional circumstances allow pharmacies to bill both third parties at same time.

According to OHIP+ guideline — Households with high out-of-pocket prescription drug expenses, that include children and youth who are covered under a private plan, can apply to the Trillium Drug Program (www.ontario.ca/trilliumdrugprogram). The Trillium Drug Program is available to all OHIP-insured Ontarians who have high prescription drug costs compared to their household income.

Que. 14: Can I use my OHIP for medications and Private insurance for other healthcare stuff ? Is it OK to do so ?

Please refer to Question 1, 2, 5 and 10.

Moreover, Pharmacies have nothing to do with other healthcare facilities and where/how they bill their services.

Que. 15: My Pharmacist knows that I have private insurance but he keeps saying me to pretend just like you don’t have it. He is telling me that with private insurance you will pay some amount and with OHIP you will not be paying anything. In top of that, pharmacists wants me to sign and do attestation. I feel something fishy… not right ! What should I do ? Am I doing any violation of regulation ?

Whenever you are in this type of situation, its advisable to be on safe side. Acceptance and refusal of this proposal depends on your honesty and fairness to government. If you accept this proposal to save money eventhough knowing it, you are liable for that. If you refuse to do that and the pharmacist bill to OHIP, its billing malpractice. Pharmacist is liable for that and there are chances for legal actions from college if they come to know. Pharmacists can be under more subsequent consequences !

Thanks for reading…!

I hope I have answered all questions. Feel free to ask questions in comment. Happy to help you !