Drug Coverage Info
This section provides information on drug coverage options and explains public coverage through the Ontario Drug Benefit Program. Contact us if you are having trouble paying for your medications or understanding your insurance coverage options.
Deductible = amount your plan wants you to pay before it will cover your medication costs
Co-pay = the portion your plan wants you to pay for each prescription
Public Drug Plan (ODB)
Public coverage is provided through the Ontario Drug Benefit (ODB) for Ontario residents. The following are included in this coverage:
- those under 25 without private coverage (this is called OHIP+)
- seniors 65 and over
- if you are receiving support through Ontario Works (OW) or the Ontario Disability Supports Program (ODSP)
- for someone receiving professional home and community care
- living in a long-term care home, home for special care, Community Home for Opportunity
- Trillium (which anyone with an active health card can apply to free)
This is a private plan that may be through a family member, your workplace, or school. You or your workplace will cover the cost of this type of insurance. Depending on your plan only certain medications might be covered and those that are covered might not be covered fully. Some plans may also require a special authorization form for the prescriber to complete (we can help with this) before covering the medication.
If you have private insurance but do not have full coverage of your medications, you can apply to Trillium for additional support. (see below re: Trillium)
There are also free programs available from some drug companies to assist with the cost of your medication. This applies to certain brand name HIV treatments only (does not apply to PrEP or PEP). Speak to your HIV specialist or contact us for more information to connect you with this program.
What is covered under ODB?
The ODB program has a list of medications that it covers – this is called the “formulary”. Not all medications are covered but PrEP, PEP, and many HIV treatment medications are. For medications that are not covered, your doctor may be able to request special coverage or switch you to something that is. You can check what is covered through this link: https://www.ontario.ca/page/check-medication-coverage/
If something is covered by ODB is it free?
The ODB program sets a co-payment of $2 for certain plan members (eg. OW, ODSP), however we reduce this at our pharmacy and you pay $0.
For people 65+ the program has two categories: “low income” and “high income” seniors. Low income seniors are charged a $2 co-pay per prescription which we reduce to $0. High income seniors pay $100 towards their medication costs per year and then have a co-pay of $6.11 per prescription. We reduce the $6.11 co-pay to $0. There is a form available here to apply to be considered a low-income senior and potentially have the annual $100 charge removed: http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/GetFileAttach/014-3233-87~1/$File/3233-87E_re.pdf
How to get covered though OHIP+
You are automatically covered if you are an Ontario resident under 25 and do not have private insurance coverage. You will need to let us know that you do not have other coverage. There is no charge for medication covered through OHIP+. This means you will not be charged for PrEP, PEP, and many HIV medications.
How to get covered through Trillium
To get coverage through Trillium you will need to submit this form: http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/GetFileAttach/014-3693-87E~3/$File/3693-87E.pdf. The program considers your income and sets a deductible to pay each quarter (every 3 months) before it will cover your remaining drug costs. The deductible is based on ~4% of your net income for the year. You can calculate an estimated annual deductible here: http://hivnow.ca/deductible-calculator/
Trillium has a $2 co-pay once you have reached your deductible, however we reduce this to $0 at our pharmacy.
Sample example: Trillium has set a patient’s deductible at $400 for the year with $100 set each quarter. The patient will be expected to pay $100 out of pocket at the start of the first quarter and then the remaining amount of this medication will be fully covered until the next quarter.
Other Drug Coverage Options
There are also free programs available from some drug companies to assist with the deductible of your medication – in many cases it may cover all of it. This applies to certain brand name HIV treatments only (but does not apply to PrEP or PEP). Contact us for more information to connect you with this program or speak to your HIV specialist.
Ways to Save Money
Dispensing Fee Savings
Our dispensing fee of $7.96 is substantially lower than most pharmacies in the province. This can result in savings of up to $50 per year per medication if you pay out of pocket for your medications. It also provides plan savings to your insurance plan.
Shipping is free in Canada for PrEP, PEP, and HIV medications.
Pharmacist Medication Assessment
If you are on multiple medications the pharmacist can assist you to review your medications and discuss options to reduce the numbers of pills or medications you take per day. Strategies can include: tapering and/or discontinuing medication that is no longer needed, finding combination medications to reduce the amount of pills, considering closely related medications that act similarly and are cheaper, or suggesting over the counter replacements where possible. The pharmacist would forward the suggested plan to your doctor. These recommendations typically more apply to non-HIV specific medications.
Generic medications are medications with the same active drug ingredient as the initial brand manufacturer. Generic drugs go through very strict protocols to be sold in Canada and in Ontario have to demonstrate they are equivalent prior to being available to market. If you are on brand medication, there may be a cheaper generic and equally effective alternative. This more often applies to non-HIV specific medications as many branded HIV medications do not yet have generic options.
In some cases a lower strength of your medication may actually be cheaper. For example, two 5mg tablets of your medication may be cheaper than one 10mg tablet in some situations. Another example is combination medications. In some cases it is cheaper to access the medications individually vs in a combination pill. We take this into account and other various considerations that can affect your medication cost.