Medication coverage in Ontario

Private medical insurance

What is it?

These are benefits that you and/or your employer pay for. Medications are usually included under medical benefits, which also often include coverage for dental, vision and paramedical services.

What should I know about it?

Each employer negotiates their plans with the insurance provider. This means two different companies could have coverage from the same insurance provider, but their plans could cover different things.

You should be sure to know the following things about your insurance plan:

• Does my insurance cover the drug prescribed?
  You can find out by getting the DIN (drug identification number) from your health-care team and calling your insurance provider to ask if that DIN is covered. Some insurance providers also have an online portal where you can enter the DIN to find out right away if it is covered.
  Sometimes, insurance providers will only cover a medication if the patient meets certain criteria. This is common for high-cost medications and/or medications for rare diseases. In these situations, your health-care team will need to complete and submit a Prior Authorization form. If a Prior Authorization form is needed, talk to your health-care team about whom it should be sent to.
• How do you pay for the medications?
  Insurance plans can have a variety of coverage structures. It is important to review your plan to understand how much of the cost you may be expected to pay when picking up medication. Some language to keep an eye on would be:
  
  • Deductible: a fixed amount must be paid by the patient before the insurance coverage begins. This can be set at a patient or family level. This is often set on an annual basis but can also be set as per claim.
  • Co-insurance: the insurance plan covers a proportion of the medication cost (e.g., 60%, 80% or even 100%) while the balance is paid by the patient.
  • Co-payment: regardless of the medication cost, the patient is responsible for a fixed amount per dispense (i.e., the patient pays $5 regardless of medication cost) while the insurance covers the rest.
  • Dispensing fee: all pharmacies charge a fee for the service of dispensing medication. An insurance plan may cover part of, all of, or none of this cost and it may vary based on which pharmacy you are getting your prescriptions from.
  • Pay and submit: the patient pays the full cost upfront and submits the receipts to their insurance provider, who reimburses the patient for what is deemed a covered expense.
  Some medications have patient assistance programs that will help with a co-pay, co-insurance or deductible. Ask your health-care team about these programs if you have concerns about the amounts you need to pay.
• Does my insurance have any maximums for medication coverage?
  These could be annual maximums or lifetime maximums. The maximum may be applied per individual or per family. Any amount above the maximum is not covered. Not all plans have maximums, but it is important to know if yours does.

Public insurance

The Ontario Drug Benefits (ODB) program is a drug benefit program for people who qualify for provincial medication coverage. The list of medications that are covered is called the ODB Formulary.

How do I qualify for provincial medication coverage?

There are several ways for children and youth to qualify for provincial medication coverage.

• OHIP+: Any Ontario resident (with a valid health card) under 25 years of age without any private medical insurance is covered under OHIP+. You do not have to fill out any applications. If your child is enrolled in private insurance and the cost remaining after the coverage is very high, speak to your health-care team about options to help manage these costs.
• Trillium Drug Program: This program is for people with very high medication costs who do not have insurance or who are not covered by their medical insurance, for medications listed on the ODB Formulary. Ontario residents can apply and everyone who files taxes will be approved if they meet the criteria. The program requires patients to pay an annual deductible (approximately 4% of net household income), which is split up and paid in quarters (e.g., 1% of net household income every 3 months) before the provincial government pays for the remaining cost. The entire household would be covered by the Trillium Drug Program. If your family has a need for this program, talk to your health-care team. More information about the Trillium program can be found at: https://www.health.gov.on.ca/en/pro/programs/drugs/funded_drug/fund_trillium.aspx.
• Assistance for Children with Severe Disabilities (ACSD) Program: This program provides financial support for low-income families who have a child with severe disabilities. More information about the ACSD Program can be found at: https://www.ontario.ca/page/assistance-children-severe-disabilities-program.
• Ontario Disability Support Program (ODSP): This program provides health and disability-related benefits to adults over 18 years old with disabilities. This includes ODB coverage for the recipient and their children. More information about the ODSP can be found at: https://www.ontario.ca/page/ontario-disability-support-program.

What does the ODB Formulary cover?

There are different levels of benefits under the ODB Formulary:

• General benefits: ODB covers most of the cost of about 5,000 prescription drug products. The prescriber only needs to write a prescription for these to be covered.
• Limited Use (LU) drugs: ODB covers most of the cost of these medications if the patient’s condition satisfies specific conditions. The prescriber needs to write the LU code on the prescription for the medication to be covered.
• Exceptional Access Program (EAP): This is a program to help pay for medications that are not covered by ODB. Medications on the EAP list are usually high-cost and patients must meet a list of pre-specified criteria to qualify for coverage. The prescriber submits a request for coverage to the Ontario Ministry of Health and Long-Term Care. More information about the EAP can be found at https://health.gov.on.ca/en/pro/programs/drugs/eap_mn.aspx.