9.8 — Drug benefits
Summary of regulation
A member of the benefit unit is eligible for drug coverage if income support is being paid on their behalf.
Coverage is for the cost of drugs prescribed by an approved health professional. The drug must be included in the Ontario Drug Benefit (ODB) Formulary and purchased from a dispensary in a month when the person needing the drug is a member of the benefit unit.
Those who are eligible for Extended Health Benefits and Transitional Health Benefits also receive drug coverage.
Intent of policy
To ensure that eligible ODSP benefit unit members receive drug coverage.
OHIP+: Children and Youth Pharmacare (OHIP+)
Members of a benefit unit who have OHIP coverage and are 24 years of age and under will access prescription drugs through the OHIP+ program of the Ministry of Health and Long-Term Care (MOHLTC).
- benefit unit members have access to the same drugs that are covered under ODSP, i.e. drugs on the ODB Formulary and drugs available under the Exceptional Access Program (EAP) of MOHLTC
- enrolment is automatic
- there is no co-pay
- eligibility ends on the person’s 25th birthday
Accessing the Drug Benefit
To access drug coverage, all members of the benefit unit, regardless of age, need to present their Ontario health card to a pharmacist along with their prescription.
Members of the benefit unit who do not have a valid Ontario health card can use other forms of government identification. These include: a driver’s licence, the ODSP Statement of Assistance, an Ontario photo identification card or a passport. Visit the ministry’s website for a complete list of approved types of identification.
Removal of all paper drug cards
For individuals with temporary health reference numbers who receive a monthly payment (Direct Bank Deposit, Reloadable Payment Card or cheque), the last paper drug card (for the April benefit month) will be sent in March 2018 with the statement of assistance. The April drug card can be used for the months of April, May and June 2018.
After June, individuals can access drug benefits with an Ontario health card or one of the other approved forms of identification as noted above.
Individuals with temporary health reference numbers who are receiving Extended Health Benefits, the Transitional Health Benefit or a zero cheque amount will receive their last paper drug card (for the July benefit month) at the end of June 2018. This card can be used only for the month of July 2018.
After July, the individual can access drug benefits with an Ontario health card or one of the other approved forms of government identification.
In cases where an individual does not have any government identification, a manual drug card can be provided for the month they are eligible.
No $2.00 co-pay if under 25 years of age
Pharmacists can charge a $2 co-pay for each prescription for those 25 years of age and older. However, many pharmacists waive this fee. Under the ODB program, co-pays cannot be charged to any member of a benefit unit who is under 25.
Drugs covered – ODB formulary and exceptional access program
Coverage is provided for the cost of drugs listed on the ODB Formulary administered by MOHLTC.
Under the Exceptional Access Program (EAP), a physician may request coverage for drugs not listed on the Formulary. Requests can also be made to the EAP in cases where drugs on the Formulary have been tried and do not work.
Additional information about the EAP is available on the MOHLTC website.
Information about the EAP and the ODB is also available by calling the ServiceOntario Infoline:
Ontario Drug Benefit Program – other classes of eligibility
In addition to ODSP and Ontario Works benefit unit members, other classes of persons are also eligible for drug coverage under the ODB program. This includes persons who have OHIP coverage and are:
- 24 years of age or under (OHIP+)
- People 65 years of age and older
- Residents of long-term care homes under the Long-Term Care Homes Act, 2007
- Residents of homes licensed under section 5 of the Homes for Special Care Act
- People receiving professional services under the Home Care program
- Trillium Drug Program recipients
Leaving ODSP – Trillium Drug Program
Trillium Drug Program benefits are available to individuals and families not on social assistance who have OHIP coverage and have high drug costs relative to their income. ODSP recipients who exit the program and are not eligible for Extended Health Benefits or the Transitional Health Benefit should be referred to the Trillium Drug Program.
In order to ensure that people leaving ODSP have their Trillium applications processed as quickly as possible, staff should:
- use the Trillium application form. Application kits are available by calling MOHLTC at 1-800-575-5386 or by downloading the Application for Ontario Drug Benefits and A Guide to Your Application (Ontario Drug Benefit). Application kits are also available at local pharmacies
- write "Personal and Confidential: Manager, Trillium Drug Program" on the outside of the envelope for the application and send to the address on the application form
By assisting applicants in completing the form, ODSP staff can help ensure the application is completed accurately.
For inquiries regarding the Trillium Drug Program:
Tel: 416-642-3038 Fax: 416-642-3034 Toll-free: 1-800-575-5386 TTY: 1-800-387-5559