• A) How the Ontario Drug Benefit program works

    The Ontario Drug Benefit program is the most common route for drug cost assistance. ODB covers four categories of medications. Different rules apply to each category. You can see the categories below, in the order of least complex to most complex.

    • i) Formulary list:

      The Ontario Drug Benefits formulary contains a big list of drugs. They tend to be
      medications that many people take. Simply show the pharmacist your coverage details.

    • ii) Facilitated Access:

      This is a special list of drugs. Only certain doctors may prescribe them. The doctor must
      have authorization in a special category. The term used is “facilitated access.” Your
      assigned physician usually has registration under facilitated access. Most medications for
      HIV/AIDS are in this category. A doctor in training might write the drug prescription. That
      doctor might not be under facilitated access. Check the doctor’s name and signature on the
      prescription and on the drug receipt. Make sure the doctor is on the registered facilitated
      access list. Pharmacies can check this for you.

    • iii) Limited Use:

      The Limited Use category is another special list of drugs. ODB covers them under certain
      circumstances. The physician writes the relevant code number on the prescription. The code
      represents two things: the product, and the patient needing the product for medical reasons.
      The physician must be under facilitated access.

    • iv) Exceptional Access Program:

      This is a final list of drugs not on the ODB formulary. Your physician applies for coverage
      on a paper form. The form is separate from the prescription. This program was formerly
      called Individual Clinical Review (Section 16). When the request is granted, coverage is
      allowed for a limited period of time. Your doctor or nurse may reapply later for renewal.
      The physician must be under facilitated access. Sometimes, the drug will move to lower
      levels of complexity. For example, it might move to Limited Use (or skip that step), then
      Facilitated Acess.

      Please note that ODB coverage is not comprehensive. It does not cover all dispensing fees.
      ODB does not cover most investigational and complementary/alternative therapy products. If
      you are not in a study that provides these medications free of charge, you must pay for them
      yourself.

  • B) How to qualify for ODB assistance

    There are four ways that Ontario residents may qualify for ODB assistance.

    • i) Social Assistance: Ontario Works (local Social Services), or Ontario Disability
      Support Program

      These two social assistance programs provide a monthly ODB slip. The slip is attached to
      your cheque or benefit payment stub. Clinic social workers and AIDS Service Organizations
      can help you access these programs. A Clinic social worker or a benefits counselor at the
      Toronto PWA Foundation can give you more information. The Ontario AIDS Network’s Online
      Benefits Information section contains more detailed information. Look for it under the
      Programs and Services section of their website.

    • ii) Community Care Access Centres’ home care programs

      Some patients receive Home Care Service through a CCAC. Home care programs provide
      professional services. These services help ill people live independently. These services may
      be nursing and personal care assistance. CCAC provides an ODB slip to cover medication
      costs. This is usually automatic. This pathway into ODB expires when home care services end.

    • iii) Seniors with OHIP

      Persons age 65 and older obtain their medications free of charge. ODB covers the costs. The
      senior presents the OHIP card at the pharmacy. Higher income seniors usually pay an annual
      copayment deductible of $100.00 (beginning each Aug. 1st) and higher dispensing fees.

    • iv) Trillium Drug Program

      The Trillium Drug Program (TDP) assists with drug costs for residents in Ontario. You must
      have a valid Ontario Health Insurance Program (OHIP) card. You pay a co-payment, called a
      deductible. The deductible is approximately 4% of your taxable household income for a
      calendar year (January 1st to December 31st). The TDP operates on a fiscal year, August 1st
      to July 31st. You pay the deductible in quarterly installments. You can apply anytime during
      the fiscal year as a new applicant. You will renew each year. Your tasks for renewal depend
      on a number of factors. For more information, refer to the instructions guide, application
      or government website.

      Guide to Understanding the Trillium Drug Program
      Application for Ontario Drug Benefits Form
      http://www.health.gov.on.ca/en/public/forms/odb_fm.aspx
      Your pharmacist uses your Ontario Health Insurance Program (OHIP) card to access the TDP
      coverage. In most cases, it is all done electronically. You pay the deductible co-payment at
      the pharmacy. Paper application packages include the guide and an application form. These
      are available in most pharmacies, or you contact TDP and they will mail it to you.

      Trillium Drug Program

      PO Box 337, Station D

      Etobicoke, ON M9A 4X3

      Toronto: 416-642-3038

      Fax: 416-642-3034

      Toll Free: 1-800-575-5386

      Email: trillium@resolve.com

    Helpful Tips When Using Trillium Drug Program:

    It is important to read and completely understand the instructions guide. The guide is too detailed
    to reproduce or summarize here. However, below are some tips about avoiding common TDP enrolment and
    usage problems. Some of the tips relate to protecting your privacy.

    Use the person names as they are stated on the OHIP registrations. OHIP must be current. If OHIP is
    expired, the file is not registered, or the file is put on hold pending OHIP renewal.

    Enrolment in Trillium Drug Program does not identify you as someone living with HIV/AIDS. However,
    one piece of correspondence can contain the names of HIV medications. It is the medication summary
    sheet. TDP would mail this to your address. This happens if you mail expense claims (drug cost
    receipts). You would mail such claims to TDP if you spent money on drugs before enrolment.
    Alternatively, you would mail claims if private insurance covers a portion of the costs. In that
    case, you must submit your portion of the costs by mail. The medication summary sheet TDP sends you
    shows the amounts you paid towards your quarterly deductible. It may include a reimbursement cheque.

    For TDP, you can use a mailing address that is not your true mailing address or physical address.
    This may better protect your information. It could be the address of a trusted friend, for example.
    In that case, it will likely differ from your OHIP address. For example, you can enter in the
    mailing address section: care of John Doe, etc. Enter your physical address below the mailing
    address. A simple letter of explanation for the “care of” address must accompany the application.
    This is not intended to force you to provide private information about your illness. For example,
    you can state in the letter that it is convenient to use the “care of” address. The explanation
    requirement intends to ensure that TDP can cross-check your signature with the signature on your
    application. In other words, it is designed to protect you.

    This strategy will work smoothly if all your medications are billed directly to TDP by the
    pharmacist. However, if you submit receipts or copies of receipts (with accompanying insurance
    statements) to TDP the address on the medication receipt must correspond to the mailing address on
    your TDP file. Technically, the address on the medication receipt is not required, so you could ask
    the pharmacist to omit it. If the receipt contains your physical address, enclose a letter each time
    to TDP that explains it is your physical address and that your mailing address is not contained on
    the receipt because you had elected to file a mailing address that differs from where you reside.

    The “Universal Child Care Benefit amount” is deducted from (not added to) “Net Income”. Therefore,
    your deductible will be reduced by about $50.00 per child under age 6.

    It is important to budget from quarter to quarter during the TDP fiscal year. Any unpaid deductible
    amount in a quarter is “rolled over” (automatically added) to the next quarter. However, unpaid
    deductible amounts are not carried forward to the next program year.

    The enrolment start date requires careful consideration. If you do not notice this section, tucked
    away at the bottom of page 2, you may miss it. In that case, Trillium Drug Program will set the
    enrolment start date as August 1st . You should backdate it within the current TDP fiscal year (no
    earlier than August 1st) if you have spent an amount of money on medications that exceeds what your
    deductible for that period would have been. You should backdate it within the previous TDP fiscal
    year (no earlier than August 1st of the previous fiscal year) if you have spent an amount of money
    on medications that exceeds what your deductible for that period would have been AND you have
    applied for enrolment for the previous fiscal year no later than September 30th of the current
    fiscal year and submit receipts no later than October 31st of the current fiscal year.

    If not backdating the enrolment start date, you enter either the current date or a future date. Be
    careful that you do not use the current date if you do not anticipate needing medications in the
    near future where the costs exceed your deductible. Be careful that you do not use a date projected
    into the future if it is possible you will need expensive medications prior to that future enrolment
    date. You can consult with your physician about these timing questions. In general, if you are well
    organized with the required documentation you can apply for TDP at the time you need it. If the
    application is in order, you can expect to be enrolled within two weeks.

    The information provided in the TDP Guide and the application about “household unit” can be
    confusing. On page 3 of the guide, the definition is: “a single person or two or more people who are
    dependent on each other financially”. This implies a reciprocal dependence rather than a unilateral
    hierarchical dependence. On page 18 in the guide, a household unit is defined as “the members that
    make up a household”, and it is stated that “a single person may be a household unit for TDP
    purposes”. However, some applicants are not sure if the term “single” is to be taken to mean
    non-married or taken to mean a person as an individual or sole entity. The definition on page 3 of
    the guide does little to clarify, as it does not reference marriage, a conjugal relationship, or a
    common-law relationship that could be taken as a contextual basis upon which to interpret the term
    “single”.

    On page 3 of the guide, the applicant is referred to page 2 of the application for a definition of
    household unit. This is where things get somewhat clearer, and there are basically four possible
    household units. A household can be compromised of a single person of at least age 16 living alone
    (though income documentation is required only for those 18 years of age and older); two persons who
    are spouse (legally married), common-law spouse, or same-sex partner to each other; either of the
    first two family units along with children, parents or grandparents residing with the single person
    or couple, where reliance for financial support is in one direction or reciprocal; or either of the
    first two family units along with children who are students, who may not live with the single person
    or couple, but rely on the single person or couple for financial support (in one direction).

    In Ontario the definitional requirements for common-law spousal status are being in a conjugal
    relationship and at least one of three conditions apply: have been cohabiting for no less than one
    year, are together the parents of a child, or have entered into a cohabitation agreement

    If you report drug coverage insurance, make sure you enter the premium you pay, or zero. If you
    leave it blank the TDP application may be put on hold.

    Sometimes, but rarely, another enrollee happens to be in the program at the same address as yours.
    For example, a tenant at your address may be in the TDP. In that event, notice is sent to person 1
    of the new application. The application is returned to person 1, indicating that both the new
    applicant(s) and the previous enrollee at or previously (but without notice of address change) at
    that address have to write and cosign documentation that they are not spouses and they are not
    financially interdependent.

    Sometimes TDP enrollees want to know what amount of medication supply can be filled at one time.
    This depends on the date within a quarter and the date within the TDP fiscal year. You can ask your
    pharmacist or contact TDP with questions about supply quantity guidelines.