What is OHIP+ and Birth Control Coverage?

OHIP+, also known as the Ontario Health Insurance Plan Plus, helps young people in Ontario get free prescription drugs. It covers many medications, including some birth control methods, for those who qualify. Understanding what OHIP+ covers can save you money and ensure you have access to the contraceptives you need.

Definition and Scope of OHIP+: OHIP+ is a program that offers free prescription drugs to Ontario residents aged 24 and under. It includes over 4,400 drug products. You do not need to pay for these medications if you meet the criteria. This program is part of Ontario's effort to make healthcare more accessible to young people.

To qualify for OHIP+, you must:

• Be 24 years old or younger (see below if you’re over the age of 24)
• Have a valid Ontario Health Card.
• Not be covered by a private insurance plan.

If you meet these criteria, you can get your prescribed medications for free. This includes some birth control options.

Overview of Birth Control Methods Covered by OHIP+: OHIP+ covers various types of birth control. Here are some that are definitely covered:

• Combined Oral Contraceptive Pills: Examples include Alysena 21, Alysena 28, Aviane 21, Aviane 28.
• Emergency Contraceptive Pills: Brands like Plan B and Contingency 1.
• Other Methods: Depo-Provera injection, Kyleena IUD, Mirena IUD, Nexplanon implant.

Age Restrictions and Implications for Coverage: OHIP+ only covers individuals up to the age of 24. Once you turn 25, you are no longer eligible for this program. This means you will need to find another way to cover your birth control costs, such as through private insurance or other government programs like Ontario Works or the Ontario Disability Support Program. Planning ahead with your healthcare provider can help ensure you continue to have access to the birth control you need after turning 25.

Without OHIP+ coverage, birth control can be expensive. For example:

• Birth Control Pills: These can cost between $20 and $50 per month.
• IUDs: An intrauterine device can cost up to $400.
• Emergency Contraceptives: These can cost around $40 per dose.

How to Determine if Your Birth Control is Covered by OHIP+

Steps to Check Coverage via the Ontario Drug Benefit Formulary: The Ontario Drug Benefit Formulary is your go-to resource for checking if your birth control is covered by OHIP+. Here's how to use it:

1. Visit the Website: Go to the Ontario Drug Benefit Formulary website.
2. Search for Your Medication: Use the search bar to enter the name of your birth control method.
3. Review the Results: Check the details to see if your specific brand and type are listed.
4. Note Any Restrictions: Some drugs may have specific conditions or limits on the number of units covered.

Role of Healthcare Providers in Verifying Coverage: Your healthcare provider plays a crucial role in verifying birth control coverage:

• Consult Your Doctor: Discuss your birth control options with your doctor. They can suggest alternatives if your preferred method isn't covered.
• Prescription Details: Ensure your prescription includes all necessary details. Sometimes, the formulation or dosage can affect whether it's covered.
• Pre-Approval for Exceptions: If your doctor thinks you need a specific brand not covered by OHIP+, they can help you apply through the Exceptional Access Program (EAP).

Explanation of Drug Product Listings and Restrictions: Not all birth control methods are covered equally under OHIP+. Here’s what you need to know:

• Brand vs. Generic: Generic versions of medications are often covered when branded ones are not.
• Quantity Limits: Some birth control pills are covered only in specific pack sizes, like 21-pill or 28-pill packs.
• Conditional Coverage: Certain methods might be covered only if you meet specific health criteria. Your healthcare provider can help determine if you qualify.

Contacting Local Ontario Pharmacists for Assistance: Pharmacists can be a great resource:

• In-Person Consultation: Visit your local pharmacy and ask the pharmacist to check if your birth control method is covered.
• Medication Alternatives: Pharmacists can suggest covered alternatives if your preferred method isn't available.
• Additional Support: They can assist with the paperwork required for the Exceptional Access Program if your specific birth control method needs it.

Definitely Covered Birth Control Methods

Combined Oral Contraceptive Pills

Combined oral contraceptive pills, often called "the pill," are one of the most common birth control methods covered by OHIP+. These pills contain both estrogen and progestin.

List of Specific Brands Covered:

• Alysena: Available in both 21-pill and 28-pill packs.
• Aviane: Offers 21-pill and 28-pill options.
• Brevicon: Covered in 21-pill and 28-pill formulations.
• Cyclen: Both pack sizes are covered.
• Loestrin: Available in 21-pill and 28-pill packs.
• Tri-Cyclen: Offers both 21-pill and 28-pill options.

Differences Between 21-Pill and 28-Pill Packs:

• 21-Pill Packs: These contain 21 active pills with hormones. After finishing these, you take a 7-day break with no pills or take placebo pills if provided separately.
• 28-Pill Packs: These include 21 active pills and 7 placebo pills, allowing you to take one pill each day without a break.

Emergency Contraceptive Pills

Emergency contraceptive pills (ECPs) are used to prevent pregnancy after unprotected sex or contraceptive failure. They are covered under OHIP+ in specific situations.

Brands and Situations Where These Are Covered:

• Plan B: Effective within 72 hours after unprotected sex.
• Contingency 1: Another brand that provides emergency contraception within 72 hours.
• Backup Plan One-Step: Similar to Plan B and used in the same time frame.

ECPs are intended for occasional use and should not replace regular birth control methods.

Other Methods

Depo-Provera Injection: This is an injectable form of birth control that you receive every three months. It contains the hormone progestin, which prevents ovulation.

Kyleena and Mirena IUDs: Both are intrauterine devices (IUDs) that release small amounts of hormone locally within the uterus. Kyleena can last up to 5 years, while Mirena is effective for up to 7 years.

Nexplanon Implant: This is a small, rod-shaped implant inserted under the skin of your upper arm. It releases progestin and prevents pregnancy for up to 3 years.

Birth Control Methods Not Covered by OHIP+

Newer Oral Contraceptive Pills

Not all birth control pills are covered by OHIP+. Some newer brands are excluded from the coverage list. The reasons include higher costs and the availability of cheaper, generic alternatives.

Explanation of Why Certain Brands Are Not Covered:

• Higher Costs: Newer birth control pills often come with a higher price tag. OHIP+ aims to cover effective yet affordable options.
• Generic Alternatives: Many newer pills have generic counterparts that are less expensive. These generics offer similar effectiveness and safety profiles, making them a more cost-effective option for the health program.

Contraceptive Patches and Rings

Some birth control methods, like patches and rings, are not covered by OHIP+. These methods provide unique advantages but also come with higher costs.

Evra Patch and Nuvaring Specifics:

• Evra Patch: This is a weekly skin patch that releases hormones to prevent pregnancy. It needs to be changed every week, making it convenient but also more expensive.
• Nuvaring: This is a flexible ring inserted into the vagina and left in place for three weeks. It releases hormones similarly to pills and patches. The cost and the specific way it is used contribute to its exclusion from OHIP+ coverage.

Non-Hormonal IUDs

Non-hormonal intrauterine devices (IUDs) offer a long-term birth control solution without hormones. However, they are not covered by OHIP+.

Details on Copper IUD and Jaydess IUD:

• Copper IUD: This device uses copper to prevent pregnancy and can last up to 10 years. It is hormone-free, making it a good option for those who prefer to avoid hormones. However, its higher initial cost and the fact that it is a non-hormonal option are why it is not covered.
• Jaydess IUD: Although it is a hormonal IUD, Jaydess is not covered by OHIP+ due to its higher cost compared to other covered IUDs like Kyleena and Mirena. Jaydess lasts for up to 3 years and is slightly smaller in size, which some users may prefer.

Understanding which birth control methods are not covered by OHIP+ helps you plan better and discuss alternatives with your healthcare provider.

It’s Complicated: Conditional Coverage for Certain Birth Control Methods

Criteria for Conditional Coverage and the Role of Generic Counterparts

When it comes to OHIP+ birth control coverage, some methods fall into a gray area. Conditional coverage means that OHIP+ may cover certain birth control methods under specific circumstances.

Criteria for Conditional Coverage:

• Generic Counterparts: If a generic version of a birth control method exists, OHIP+ prefers to cover that instead of the brand-name version. Generics are usually cheaper but offer the same effectiveness.
• Cost-Effectiveness: Methods that provide similar benefits but at a lower cost are prioritized for coverage. This ensures that more people can access birth control without high expenses.

Health Reasons That Might Qualify for Coverage Exceptions

Sometimes, your health needs might require a specific birth control method that isn’t typically covered by OHIP+. Coverage exceptions are possible if your healthcare provider can demonstrate medical necessity.

Health Reasons That Might Qualify:

• Allergies: If you are allergic to ingredients in generic options, a brand-name version might be necessary.
• Side Effects: Severe side effects from a generic version may lead your healthcare provider to prescribe a more suitable but usually non-covered brand.
• Specific Health Conditions: Conditions like hormonal imbalances or menstrual disorders might require a specific type of birth control.

Process for Applying Through the Exceptional Access Program (EAP)

If you need a birth control method not usually covered by OHIP+, you can apply for coverage through the Exceptional Access Program (EAP).

Steps to Apply for EAP:

1. Consult Your Healthcare Provider: Discuss your need for a specific birth control method and why alternatives are not suitable.
2. Complete the EAP Application: Your healthcare provider fills out the necessary forms and includes medical reasons for your request.
3. Submit the Application: Send the completed forms to the EAP office. This can often be done online or through your healthcare provider’s office.
4. Wait for Approval: The EAP reviews your application and decides if the birth control method will be covered based on your medical needs.

Types of Oral Contraceptives Under Conditional Coverage

Some oral contraceptives may be covered under OHIP+ but only under certain conditions. These typically include specific brands that are more expensive or newer than generics.

Oral Contraceptives Under Conditional Coverage:

• Alesse: Often covered if generic versions cause adverse reactions.
• Apri: Similar to Alesse, covered if generics are unsuitable.
• Marvelon: May be covered for specific health reasons.
• Yaz: Conditional coverage if other options aren’t effective or cause severe side effects.

Understanding the conditional coverage rules helps you and your healthcare provider navigate the complexities of OHIP+ birth control coverage. Knowing these details can make accessing the right birth control method easier and more affordable.

How to Navigate Coverage After Turning 25

Turning 25 brings significant changes to your healthcare coverage, especially under OHIP+. At this age, you are no longer eligible for OHIP+ coverage, which means you need to find new ways to cover your birth control and other medical expenses.

Explanation of Life Changes at Age 25 Regarding OHIP+

When you turn 25, you age out of the OHIP+ program. This program provides free prescription drugs, including birth control, to individuals 24 years old and younger who do not have a private insurance plan. After your 25th birthday, you must look for alternative coverage options.

Options for Individuals Transitioning Off OHIP+ Coverage

Transitioning off OHIP+ can feel overwhelming, but several alternatives can help you maintain coverage for your birth control.

Options to Consider:

• Private Insurance: Look into employer-provided health plans or private insurance policies. Many employers offer health benefits that include prescription drug coverage.
• University Health Plans: If you are a student, your university might offer health insurance that covers prescription medications.
• Family Coverage: Some private insurance plans allow you to stay on your parent’s insurance until age 26, depending on the policy.

Potential Eligibility for Ontario Works and Ontario Disability Support Programs

If you find yourself without coverage after turning 25, you may qualify for assistance through Ontario Works or the Ontario Disability Support Program (ODSP).

Eligibility Criteria:

• Ontario Works: Provides financial and employment assistance to those in financial need. This program can help cover healthcare costs, including birth control, if you qualify.
• ODSP: Offers financial support and health benefits to individuals with disabilities. If you have a qualifying condition, this program can cover your prescription drug costs.

Steps to Plan for Future Contraceptive Needs with Healthcare Providers

Planning ahead can ensure you don’t face gaps in your birth control coverage. Taking proactive steps helps you manage your healthcare needs effectively.

Steps to Consider:

1. Schedule a Healthcare Appointment: Speak with your healthcare provider about your upcoming transition off OHIP+.
2. Discuss Long-Term Birth Control Options: Consider methods that require less frequent prescription renewals, like intrauterine devices (IUDs) or implants.
3. Explore Coverage Options Together: Your healthcare provider can help you understand which private insurance or assistance programs are best suited for your needs.
4. Gather Necessary Documentation: Ensure all your medical records and prescriptions are up-to-date to make the transition smoother.
5. Apply for New Coverage Early: Start the application process for private insurance or assistance programs before you turn 25 to avoid any coverage gaps.

Online Prescription

TeleTest offers a streamlined and efficient solution for obtaining or renewing birth control prescriptions online. With transparent information on pricing and dosages for a variety of contraceptive options, users can easily understand their potential costs, regardless of their OHIP+ coverage status. This service ensures accessible and straightforward access to essential reproductive health resources.

Disclaimer: This blog post is intended for educational purposes only and should not be taken as medical advice. Always consult your healthcare provider for personal health concerns.