In Ontario, there is an excellent governmental program for seniors (people age 65 and older) and youth (24 years of age or younger who does not have a private insurance plan) to get help paying for prescription drugs – the Ontario Drug Benefit (ODB) program.
The Ontario Drug Benefit Program
You will qualify for the Ontario Drug Benefit program when you turn 65 years old. The Ministry of Health will send you a letter about three months before your 65th birthday to let you know you will automatically join the Ontario Drug Benefit program on the first day of the month after you turn 65 years old.
This program is for Ontario residents only and prescriptions must be filled in an Ontario pharmacy to be covered. You must have your valid OHIP card to get prescription drugs at a pharmacy: your pharmacist will need your health card to confirm your eligibility.
Who else qualify for the Ontario Drug Benefit program
Some Ontarians qualify for ODB before they reach 65:
- living in a long-term care home, home for special care, Community Home for Opportunity
- 24 years of age or younger and not covered by a private insurance plan
- receiving professional home and community care services
- receiving benefits from Ontario Works or Ontario Disability Support Program
- enrolled in the Trillium Drug Program
What is covered by the Ontario Drug Benefit program
The Ontario Drug Benefit program covers most of the cost of more than 4,400 prescription drug products.
What is not covered by ODB
The Ontario Drug Benefit program does not cover the following:
- prescription drugs that you buy outside Ontario
- drugs that are not listed on the official Ontario Drug Benefit Formulary/Comparative Drug Index, or are not approved by the Exceptional Access Program
Find out if your prescription medication is covered by ODB
You can check if your medication is covered or not through the Ontario Drug Benefit program. The Ontario Drug Benefit program covers most of the cost of the more than 4,400 medications you can search for on that page.
If you are covered by the ODB program and need help paying for a medication that is not found in the search tool, it may be covered through the Exceptional Access Program (EAP) or the Limited Use drugs program.
Exceptional Access Program
The Exceptional Access Program is designed to help you paying for drugs not covered by the Ontario Drug Benefit. You and your doctor or nurse practitioner can do a search to make sure the drug you need is covered through this program.
Only your doctor or nurse practitioner can apply for the coverage for you through the Exceptional Access Program or Compassionate Review Policy. There is no deadline for these applications.
Once your application is submitted, and if it’s approved, the cost of the drug will be covered for up to 30 days prior to the date they received your application.
Coverage may last for two weeks to a lifetime, depending on the type of drug you need. How much you can get covered again depends on the drug you need, how long you have to take it and whether you already qualify for the ODB or a related program.
Limited Use drugs
If you search for a drug and it’s labelled as “Limited Use,” that means it is covered only under special medical circumstances.
When you’re prescribed one of these drugs, your doctor or nurse practitioner must confirm that your circumstances require treatment with a Limited Use drug by writing a three-digit code on your prescription, called the Reason for Use code.
If you’re given a refill by your doctor or nurse practitioner, ask to make sure it’s still available for Limited Use treatment. Some Limited Use drugs are covered for days or weeks, some for a year or years, while some are approved for lifetime coverage. You should also ask your pharmacist to check.
Sources:
- https://www.ontario.ca/page/get-coverage-prescription-drugs#section-5
- https://www.ontario.ca/page/check-medication-coverage/
- https://www.ontario.ca/page/check-medication-coverage/
- https://www.ontario.ca/page/applying-exceptional-access-program
