In 2018, Ontario introduced OHIP plus, a universal pharmacare programme providing prescription drugs to all residents < 25 years. In April 2019, eligibility was restricted to those without private insurance (OHIP minus), potentially reducing medication access, increasing costs, and compromising confidentiality for postsecondary students covered under parental plans. We conducted an environmental scan to document drug-plan cost-sharing, contraceptive coverage, and exclusions, and compared these plans with OHIP minus. Coverage varied substantially and no student plan matched OHIP’s comprehensive, no-cost-sharing coverage. These findings highlight inequities in student drug coverage and call into question the value of mandatory private plans that provide less protection than the public programme. 

 Introduction

In Canada, nearly all residents are provided tax-funded health insurance coverage without any cost-sharing for physicians and hospital services, including prescription drugs administered in hospital. Publicly funded insurance coverage for outpatient prescription drugs, however, varies widely between provinces and territories. With the exception of Québec which mandates drug insurance using a public-private mix, provincial and territorial drug insurance programmes typically provide coverage based on age (e.g., seniors) or income. Additionally, public programmes typically provide some form of catastrophic coverage, most often when out-of-pocket costs exceed a proportion of household income, and some coverage for individuals enrolled in income support programmes (e.g., low income or disability) (Brandt et al., 2018; Marchildon et al., 2020).

In 2024, Canada’s Pharmacare Act, Bill C-64 was passed by Canada’s House of Commons. It introduced single-payer, first-dollar coverage for a selection of contraception and diabetes medications – meaning no coinsurance, copayments, deductibles, premiums, or dispensing charges for listed drugs. The Act enables the federal government to work with provinces and territories to implement this coverage. It also directs Canada’s Drug Agency to develop a list of essential drugs, create a national formulary, establish a bulk purchasing strategy to reduce medication costs, and coordinate a strategy for the appropriate use of prescription drugs (Staples, 2025). Coverage only applies in provinces and territories that have signed bilateral funding agreements with the federal government. Thus far, British Columbia, Manitoba, Prince Edward Island, and the Yukon have entered into agreements to participate in the federal programme. Alongside diabetes medications and contraceptives, some provinces are extending coverage further. For example, British Columbia and Manitoba have also expanded coverage to include free access to hormone replacement therapy in their coverage plans (Government of British Columbia, 2025; Government of Manitoba, 2025)

In Canada, nearly all private prescription drug coverage is employment-based. For those under 25 years, private outpatient drug insurance is most often obtained as the dependent of an employee with private coverage or through enrolment at college or university. 

In January 2018, the Ontario government introduced Ontario Health Insurance Plan (OHIP) plus, which provided universal pharmacare, to all Ontario residents under the age of 25, including individuals already covered by private drug plans (Pullen, 2018). OHIP plus provided full coverage, without any cost-sharing, for all prescription drugs listed on the Ontario Drug Benefit (ODB) drug formulary (approximately 4000 drugs at the time). OHIP plus was unexpectedly announced in April 2017 by Ontario’s Minister of Finance (Sousa, 2017). During budget’s discussion, Kathleen Wynne, Ontario’s Premier, argued that OHIP plus was an investment in the long term health of children and youth, while MPP Yvan Baker indicated that OHIP plus was the first step toward universal pharmacare (Pullen, 2018). Commentators, however, highlighted the relatively low cost of providing drug insurance to this population (Pullen, 2018). Coverage for additional drugs not covered by the ODB formulary, could also be obtained under specific clinical circumstances through the government’s Exceptional Access Program (EAP) (Ontario Ministry of Health, 2023). In April 2019, with the aim to generate annualized savings of at least $250 million, OHIP plus was revised to cover only those who did not otherwise have private coverage, a policy change commonly referred to as "OHIP minus" (Fedeli, 2019).

College and university students who were under 25 years were directly affected by the transition from OHIP plus (full coverage, without any cost-sharing) to OHIP minus (full coverage, without any cost-sharing only for those without any private drug insurance coverage). In Ontario, college and university students are typically required to buy into complementary health insurance, which provides coverage for services that fall outside physician and hospital care. This includes coverage for prescription drugs, often in combination with dental, rehabilitative, mental health, and vision care. College and university students are not allowed to opt out of their school plans without comparable private insurance, which are most often obtained through their parents or guardians; of importance, OHIP coverage cannot be used to opt out of school plans. In 2018/2019 in Ontario, there were 184,630 college and 574,806 university full time students who were less than 25 years-old, of which 48% and 56% respectively were women (Statistics Canada, 2026).

Our objectives were to 1) document outpatient prescription drug coverage provided to college and undergraduate students by Ontario publicly assisted postsecondary institutions and 2) compare and contrast college and undergraduate student’s coverage with Ontario’s under 25 public programme, with a focus on equity and efficiency.

Methods

We conducted an environmental scan of the institutional websites of publicly funded postsecondary institutions and documented all cost-sharing components (e.g., deductibles, coinsurance, copayments, dispensing fees, annual limits). We identified institutions using a Government of Ontario database of publicly assisted colleges and universities (Government of Ontario, 2026). We included all main campuses with three exceptions: 1) Northern Ontario School of Medicine University (many medical students are ≥ 25 years); 2) Royal Military College of Canada (drug coverage provided by the federal government); and 3) Université de l’Ontario français (a new university with very low enrolment).

In documenting cost-sharing components, we paid particular attention to coverage for contraceptives. Financial barriers to contraception have been identified as a contributing factor in young Canadian women opting for less effective birth control methods, thereby heightening their vulnerability to unintended pregnancies (Black et al., 2018). Additionally, hormonal contraceptives had the highest reported prevalence of any prescription drugs in youth aged 12 to 19 years in the Canadian Health Measures Survey (Servais et al., 2021). Whenever feasible, we used drug identification numbers (DIN) to ascertain contraceptive coverage for oral contraceptives, copper and hormonal intrauterine devices (IUDs), contraceptive injections, hormonal implants, hormonal vaginal rings, emergency oral contraceptives, and contraceptive patches. At least two of us independently extracted the data. Conflicts were resolved by discussion. We also conducted multiple rounds of outreach, by email, to student associations across Ontario to assess their awareness of the student drug plans and better understand the rationale underlying their design and opt-out policies. If no response was received, a follow-up email was sent approximately one month later.

We did not examine the cost to students as it is not possible to disentangle the cost of the prescription drug component from the total health and dental plan costs; plans at universities and colleges typically include prescription drug, dental, extended health care, and accident benefits.

Results

We reviewed the outpatient prescription drug insurance plans offered by 45 publicly funded postsecondary institutions in Ontario, comprising 21 universities (Table 1) and 24 colleges (Table 2). Our analysis focused on overall cost-sharing structures in the 2024-2025 academic year. We first examined deductibles, a form of cost-sharing that requires an individual to pay the full cost of a drug until the individual’s spending has reached a specified limit. Second, we documented coverage for dispensing fees, a charge applied by pharmacies to fill a prescription. Third, we examined coinsurance, a form of cost-sharing that requires an individual to pay a proportion of the cost of a drug. Fourth, we examined coverage limits, a ceiling or maximum on the dollar amount of benefits paid to an individual over a defined period of time, typically a year (Hurley, 2010). Lastly, we examined contraceptive coverage and general restrictions on contraceptives and other drugs.

We were able to ascertain contraceptive coverage using DINs for nine universities (Algoma University, Brock University, Laurentian University, Ontario Tech University, Trent University, University of Guelph, University of Windsor, Wilfrid Laurier University, and Western University) and two colleges (Durham College and Georgian College). Overall, outreach response rates were limited: several institutions did not reply at all, while others redirected us to their insurance providers who either referred us back to the student unions or did not respond after initial contact. Only one insurance provider provided a substantive response.

Deductible

Only one of the college and university plans we reviewed included deductibles. Students at Confederation College in Thunder Bay had a choice between three plans with $0, $25 or $40 deductible per benefit-year.

Dispensing fees

Coverage for dispensing fees was typically between $5 and $12 per prescription, with some plans offering reduced or waived fees at partner pharmacies, and some plans not covering dispensing fees. One college (Collège La Cité, a French-language college located in Ottawa) and one university (Université de Hearst, a French-language university with its main campus in Hearst) did not provide any coverage for dispensing fees. These fees are charged in addition to coinsurance, meaning students may incur out-of-pocket charges for each prescription filled. 

We were unable to obtain information for three colleges (Collège Boréal, Northern College, Sault College) and seven universities (Lakehead University, McMaster University, OCAD; Toronto Metropolitan University, University of Guelph, University of Toronto, York University).

Coinsurance 

Coinsurance rates varied widely, ranging from 0% to 50%. Many institutions (eight colleges and 12 universities) applied a standard rate of 20% coinsurance for most prescription drugs. However, some plans varied their rates depending on the pharmacy used. For example, several plans offered 0% coinsurance at affiliated virtual pharmacies, most often for generic drugs, while charging higher rates at unaffiliated pharmacies (Algoma University, Brock University, Laurentian University, Nipissing University, Trent University, Wilfrid Laurier University). 

Lastly, 13 colleges permitted students to choose between plans with differing coinsurance rates, most often between 10% and 35%. Fanshawe College, located in London, offered the lowest coinsurance rates (0 to 20%) while Northern College with a main campus in Timmins offered the widest range and highest potential coinsurance rate (10% to 50%). 

We were unable to obtain information for one college (Collège Boréal).

Coverage limit

Annual benefit maximums for drug coverage varied widely. Among universities, coverage caps ranged from $1000 (Université de Hearst) to $5000 (Brock University, Carleton University, Queen’s University, Toronto Metropolitan University, University of Guelph, University of Toronto), with the University of Waterloo offering the most generous plan at $12,500 per year. 

Across Ontario colleges, annual drug coverage maximums ranged from $500 to $6,500, with most plans falling between $1,000 and $3,000 per benefit-year. Twelve colleges offered tiered plans, further contributing to inter-institutional variability. Confederation College, with its main campus in Thunder Bay, offered the least generous plans ($500 or $1000) while George Brown College, located in Toronto, offered the most generous coverage ($3000, $5000, or $6500).

Contraceptive coverage

Coverage of contraceptive methods showed considerable variation, particularly between university and college plans. Universities generally provided broader contraceptive coverage. Most university plans covered oral contraceptives, and many also included injectables, patches, vaginal rings, and IUDs. However, even when covered, these products were often subject to product-specific caps. For instance, $178 maximum per year for NuvaRing (a brand name vaginal ring) and $200 for IUDs. Only a small number of universities covered contraceptives without any cost-sharing, though these plans frequently had annual or per-product spending caps. Collège Boréal, a francophone college first established in Sudbury, specifically excluded contraceptives altogether, while three colleges (Cambrian College and Northern College, both located in Northeastern Ontario, and St-Clair College in Windsor) excluded all contraceptives other than oral.

Exclusions

Many plans imposed restrictions on specific drug categories, frequently excluding medications related to erectile dysfunction, fertility, hair loss/growth, smoking cessation, vaccines, and weight loss. Acne preparations were also often excluded, especially Accutane, a type of retinoid medication that treats severe acne. Some plans also placed lifetime caps on high-cost drug classes such as biologics or hepatitis C treatments.

Discussion

We found considerable heterogeneity in outpatient prescription drug plans between universities and colleges, creating inequities in access based on where a student is enrolled. For example, colleges located in northern Ontario appeared to provide less generous coverage with more restrictions. Importantly, none of the student-union plans reviewed compared favourably to the coverage available through OHIP. Under OHIP, eligible individuals below the age of 25 have access to all medications listed on the ODB formulary with no deductible, no coinsurance, no dispensing fees, and no annual limits. Ontario’s public drug programme currently covers approximately 5,000 medications, and funding for additional drugs may be obtained under specific clinical circumstances through the EAP. It should be noted that OHIP does not cover some devices such as copper IUDs and vaginal rings. In contrast, student-union plans imposed multiple layers of cost-sharing, routinely excluded drug categories that are particularly relevant to young adults (e.g., acne medications and some contraceptive options) and limited total annual reimbursements.

There is anecdotal evidence that some Ontario post-secondary students faced substantial cost-sharing as a result of OHIP minus. CBC/Radio-Canada documented the case of a student at Trent University with over $1,000 in monthly drug costs, with a university plan which covered a maximum of $3,000 per year, and a McMaster University student with Crohn’s disease with monthly drug costs in excess of $6000 and an annual prescription drug allowance of just $2,500 with a 20% coinsurance rate (Arangio, 2019; Mowat, 2019).

Postsecondary students with high out-of-pocket outpatient drug expenses, who are not eligible for OHIP minus, may qualify for the Ontario Trillium Drug Program (TPD). Under TDP, households are responsible for an annual deductible equivalent to approximately four percent of their after-tax income. Once this deductible is met, the programme provides coverage for medications listed on the ODB formulary, with beneficiaries required to pay only modest cost-sharing (up to $2 per prescription). At the median provincial after-tax household income in 2020 (the latest census data), this represents a deductible of more than $3000 (Statistics Canada, 2023). Since almost half of Ontario postsecondary students reported living at home in 2023, and many who do not are considered dependent for tax purposes, they must pay a considerably high deductible before receiving coverage from TPD (Ipsos, 2023).

Higher cost-sharing faced by post-secondary students as a result of OHIP minus has important health implications as it most certainly leads to lower drug utilization, given the strong association between cost-sharing and drug use (Guindon et al., 2022; Guindon et al., 2023). Emerging research suggest a positive association between OHIP plus and drug use, and negative association or levelling off between OHIP minus and drug use among children and youth in Ontario (Antoniou et al., 2023a, b; Balderrama, 2020; Downey et al., 2025; Giruparajah et al., 2022; Kitchen et al., 2025). Of note, a recent study found a positive (negative) association between OHIP plus (OHIP minus) and contraceptive dispensations (IUDs and contraceptive pills) (Downey et al., 2025). Moreover, common restrictions in college and university drug coverage may also lead to poorer health outcomes. Several college and university plans excluded vaccines from coverage, most often vaccines to prevent hepatitis B and human papillomavirus (HPV) infection. Differences in preventative vaccine coverage between schools creates inequities. In particular, for nursing and other health professional programmes where completion of the hepatitis B vaccine series, demonstration of immunity, and booster vaccination for those who do not demonstrate immunity after the primary series are mandatory (often received in elementary school). Similarly, smoking cessation medications were most often excluded from coverage, while OHIP covers prescription smoking cessation medications for those age 18 years or older and up to a year of pharmacist-assisted counselling. While tobacco use is the leading cause of preventable death, quitting smoking is beneficial to health at any age, and cessation medications increase the likelihood of successfully quitting smoking (US Department of Health and Human Services, 2014, 2020). In 2020, the US Surgeon General emphasized the importance of insurance coverage for smoking cessation: “Insurance coverage for smoking cessation treatment that is comprehensive, barrier-free, and widely promoted increases the use of these treatment services, leads to higher rates of successful quitting, and is cost-effective (US Department of Health and Human Services, 2020).”

Many of the restrictions we identified disproportionately affect conditions that already carry stigma, particularly among youth. For example, medications for smoking cessation, obesity, acne, fertility, and erectile dysfunction are often excluded, restricted, and subject to annual caps. These gaps create additional barriers for students, who may avoid seeking treatment out of fear of cost or shame. Contraceptive coverage in particular varied widely, with some institutions excluding all methods except oral contraceptives and others imposing product-specific caps. These gaps are particularly concerning given that IUDs were recognized by the Society of Obstetricians and Gynaecologists of Canada clinical practice guideline as frontline contraception for youth, highlighting the disconnect between current medical guidelines and insurance coverage (Black et al., 2015). By imposing financial and administrative barriers on treatments for sensitive health conditions, student health plans risk exacerbating inequities and discouraging students from seeking care. The importance of removing barriers to contraception is acknowledged by the Canadian Paediatric Society which “recommends that all youth should have confidential access to contraception, at no cost, until the age of 25 (Di Meglio and Yorke, 2019)."

In addition to the equity and health implications of the April 2019 changes to Ontario’s public drug programme, there are important efficiency considerations. Public insurance programmes such as OHIP are inherently more technically and cost efficient at raising funds, pooling risks, and administering the system, than private insurance such as plans for college and university students (Hurley and Guindon, 2020; Hurley, 2010). In theory, college/undergraduate student insurance in combination with OHIP minus may be more allocatively efficient than OHIP plus on its own. Although several colleges offered plan choices with differing cost-sharing and annual caps, given the mandate to join and financially contribute and that opting-out most often occurs because of a parent’s group-based insurance, it is unlikely that college/undergraduate student plans in combination with OHIP minus are more allocatively efficient than OHIP plus in practice. 

A 2022 study estimated the government cost savings associated with OHIP minus (i.e., restricting coverage to individuals without private drug insurance) to about $26.8 million per month or $321 million in the first year (Miregwa et al., 2022). Relative to Ontario’s government total expenditures in 2019 ($164.8 billion), health expenditures ($63.7 billion) and outpatient drug expenditures ($5.8 billion), this represents approximately 0.002%, 0.005%, and 0.056% of government expenditures, respectively. The cost savings are also substantially lower than the cost of some of the government’s recent policy decisions. For example, the Financial Accountability Office (FAO) of Ontario has estimated that the government’s decision to expand the beverage alcohol marketplace in Ontario from 2024 will result in a net cost of $1.4 billion to December 31, 2030 (Financial Accountability Office of Ontario, 2025). The $1.4 billion price tag is likely conservative as the broader financial costs associated with the expansion on health, social, and safety outcomes were not included in the net cost (Financial Accountability Office of Ontario, 2025). Lastly, and more importantly, the modest savings in government expenditures associated with OHIP minus is almost certainly less than the total additional costs imposed on Ontarians, given the inefficiencies inherent in private insurance, which inevitably result in higher premiums (Hurley and Guindon, 2020; Law et al., 2014).

It is unclear why student health plans at Ontario postsecondary institutions require students younger than 25 years without alternative private insurance to pay for coverage that is substantially weaker than that of the public programme. In 2019, just after the OHIP policy change, the president of Trent University’s Student Association, indicated the student union was in talks with its insurance provider on how to navigate the change, and suggested to students who aired their concerns, that they instead be directed to the province (Arangio, 2019). At McMaster University, the Student Union Vice President said “… we had no idea that these changes were coming,” we were “the last to find out (Mowat, 2019)." It now has been more than six years since the transition to OHIP minus, and yet, it appears that all publicly funded college and university student-union plans continue to require their students to pay for coverage that is weaker than the public programme (OHIP). From our student association outreach exchange, we learned from one insurance provider that student health plans are intentionally structured to provide broad coverage beyond prescriptions and to serve students who may not be eligible for public programs like OHIP (e.g., international students). Clarity around the rationale for mandatory drug coverage and heavily restricted plan opt-out policies remains limited.

Our findings have clear policy implications. First, Ontario student-unions at postsecondary colleges and universities should immediately cease to duplicate the public programme for students under 25 years. Rather, the coverage offered to under 25 students should complement the public programme. Second, our findings highlight the inefficiencies and inequities in college/undergraduate student coverage. Coverage varied vastly between institutions and the provision of 45 separate plans is not cost efficient; it compares poorly to the public programme in terms of risk pooling, system administration and financing.

These inefficiencies and inequities have important implications for the design of a national pharmacare programme, or any provincial and territorial reforms. The National Pharmacare Committee of Experts in its ‘Final Report’ called on the federal government to ensure “consistent access to essential medicines across all jurisdictions in Canada” and “free access for all people living in Canada” (Health Canada, 2025). Our examination of the provision of drug insurance to under-25 postsecondary students in Ontario illustrates the drawbacks of relying on private insurance to provide equitable and cost efficient drug insurance coverage. 

Limitations

First, we relied solely on publicly available documents from institutional websites. As such, unless specifically noted, the array of contraceptive options covered by college and university plans may be incomplete. For example, we were often unable to ascertain if devices such as copper IUDs were covered. Similarly, the list of restrictions may not be exhaustive. Second, we did not examine how students navigate these plans in practice or their level of awareness regarding drug insurance coverage. Third, our environmental scan does not allow us to make any claims about the impact of college/undergraduate student drug insurance plans on drug use, health services use, or health. 

Conclusions

Ontario’s 2019 revision of OHIP plus resulted in reduced prescription drug coverage and increased cost-sharing for many postsecondary students. Our environmental scan shows that college and university drug plans vary widely in generosity and provide coverage substantially weaker than the public plan previously available to youth under 25. These discrepancies generate inequities in access and may have adverse health and financial consequences for students, particularly those managing chronic conditions or requiring contraceptives. Given the modest fiscal savings achieved through OHIP minus relative to the broader societal costs, student health plan administrators and policymakers should reconsider the rationale for duplicative private insurance schemes and work toward models of drug coverage that are equitable, efficient, and better aligned with public pharmacare principles.

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Articles posted in the pre-release section of Healthcare Policy | Politiques de Santé have undergone peer review and have been accepted by the journal’s editors. However, they have not been copy edited. Any copy editing or proofreading changes to an article will be reflected in the final version appearing in the regular issue of the journal.

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