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Drug Coverage In Ontario

Drug Coverage in Ontario With the recent announcement from the conservative government that they will be changing the coverage for children and young adults under the age of 25 we thought it was a good time to do a blog on drug costs in Ontario. First of all lets review the different drug plans which are available through the Ministry of Health in Ontario. Below are the main public drug programs available to residents in Ontario. We are going to focus on the 3 programs highlighted, OHIP+, Trillium and the ODB Seniors Plan. The drug plans are very similar in that the for the most part they cover all the same drugs. There are some medications on the list that have restrictions on their use, and can only be used in patients over 75 years of age, or under 5 years of age etc. This generally is done for expensive medications to limit their use to those who would most benefit from the drug (although this can always be debated!). So if the drug coverage is generally the same what is different between the plans? The main difference in coverage is what you will pay for medications.

Trillium Drug Program

Coverage is determined based on your income. The government collects all of your income information (and anyone else living in the same household) and will determine your deductible. You can see the deductibles based on net income here. The deductible you are given is split up over the year so that you don’t have to pay it all at once. Below is the example of a 800 dollar deductible. The deductible is the portion that you will have to pay, lets look at 2 examples to show how this works.
  1. Your drug costs are LESS than your deductible:
    • Based on the example above if your medications cost less than 200 dollars between august and October you will pay the cost of your medications and receive no reduction in price.
  2. Your drug costs are HIGHER than your deductible:
    • In this case you will still pay the 200 dollar deductible for the first 200 dollars worth of medication, but for any prescription costs over 200 dollars you will only pay $2.00 for each prescription.
I understand that this can be very confusing, so feel free to e-mail us or call us with questions. There are also lots of scenarios which can further complicate the process for example when you get a drug which is not covered by the government it doesn’t count towards your deductible.

ODB Senior Plan

The ODB senior plan also has a deductible for seniors who are considered “higher income” earners as you can see in the image below. The deductible in this case resets every August 1st. As a result if your drug costs are less than 100 dollars per year you will only play your drug costs. If your drug costs are higher than 100 dollars you will pay the first 100 dollars and then the government copay only for each prescription, which is $6.11 per prescription.

OHIP+

For OHIP+ it currently is much easier, there is no enrolment, and no copay. This means that if you are covered by the plan and have a prescription for a covered medication you will pay nothing! The current government is planning to change this so that if you have private insurance you will not receive any government assistance. This means that you will go back to paying based on your private insurance coverage. This is slated to take place on April 1st 2019 (see the announcement here). This means that anyone under 25 without insurance will not pay for their prescriptions, and anyone with insurance will pay their usual co-pays and deductibles. Overall you can see our patchwork of plans in Ontario and why there needs to be change to ensure that all Ontarians (and Canadians) can access medications that are medically necessary. It is estimated that 1 in 10 Canadians can’t afford their prescription medications. If you have questions about drug pricing, or how to get coverage call or email us!

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