• 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 ProgramThese two social assistance programs will provide drug coverage using your valid OHIP card. Drug coverage slips are no longer issued – it is important to ensure that your OW/ODSP worker is aware of your current OHIP card information. Slips are still issued for dental care each month. 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 Those receiving Home Care that has been arranged through the LHIN or Ontario Health receive medications free of charge. ODB covers the costs associated with all prescribed medications approved under the Ontario Drug Benefit Formulary. This is accessed using your valid OHIP card, and the coverage continues as long as you are registered to receive Home Care services. This applies to those under the age of 65 as well, so long as they are registered to receive Home Care services.
  • iii) Seniors with OHIP Persons age 65 and older obtain their medications free of charge. ODB covers the costs associated with all prescribed medications approved under the Ontario Drug Benefit Formulary. High income seniors will need to be an annual deductible of approximately $100. Low income seniors can have this deductible cost waived by completing the Co-payment For Seniors application form..
  • 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.

OHIP+

Persons under the age of 25 have access to medications free of charge. Every person under the age of 25 with a valid health card is automatically enrolled in OHIP+. ODB covers the costs associated with all prescribed medications approved under the Ontario Drug Benefit Formulary. There is no deductible or co-pay required. However, those under 25 with access to private insurance (either their own or that of a family member) that covers that some or all of the cost of medication must access this coverage first. The remaining costs will be covered through the OHIP+ program. The coverage ends of the individuals 25^thbirthday.