Medications: Financial Help for Medications in Ontario
Contact your employer to see if you have a health plan that covers medications. Private insurance plans in Ontario will usually cover medications right away, or shortly after they become available in Canada. Most plans will not reimburse the whole cost of the medication. There is a ‘deductible’ which means you have to pay a part of the cost - usually 10-20% - “out of pocket.” But if the costs that you have to pay yourself are quite high, then you may qualify for coverage under Ontario’s Trillium Program.
ODB covers many prescription medications for people who:
- Receive government assistance (Ontario Works or ODSP)
- Who are over the age of 65
- Live in long-term care facilities, or Homes for Special Care
- Receive professional services under the Home Care Program
- Are registered in the Trillium Drug Program
You can get an application online, or through Service Ontario. Your physician will need to fill out a request form in some cases. You may have to pay a part of the drug costs or a dispensing fee. For more information, visit http://www.health.gov.on.ca/en/public/programs/drugs/#
This is a program for people who live in Ontario and spend a large part of their income on prescription medications. Once you spend a certain portion of your income on medications, the Trillium program will cover the full cost of most medications until the end of the program year.
You can apply to Trillium if:
- You live in Ontario.
- You have no drug coverage.
- Your private insurance does not cover 100% of your prescription drug costs. If you have partial insurance coverage, the Trillium Drug Program will cover the difference between the full cost of the medication and your insurance coverage.
- You have valid Ontario Health Insurance (OHIP) number and you are not eligible for drug coverage under the Ontario Drug Benefit (ODB) Program. You can’t receive Ontario Works (OW) or Ontario Disability Support Program (ODSP) and also be covered by Trillium.
How the Trillium Program works:
- You must submit proof of income.
- Trillium will calculate about 4% of your ‘net’ income which is your income after taxes as your ‘deductible’ which is the amount you will have to pay.
- Once you have paid 4% of your net income for medications, then Trillium will pay for the rest of your medication costs for the rest of the year. The Trillium fiscal year is from August 1 to July 31.
- Every three months or quarterly - four times a year - you will pay one-quarter of your deductible towards your medication costs.
- Trillium pays the rest once you have paid your full deductible for the three-month period. The dates you must pay your deductible are: August 1, November 1, February 1, and May 1.
For example, if your net income was $20,000.00 last year and your medications cost $500/month, Trillium would calculate 4% of $20,000 = $800.00. That is the amount you would have to pay for the whole year between August 1 and July 31. This means you would need to pay $200 every three months.
How to apply for Trillium: Application forms are available at pharmacies, clinics, some doctor’s offices and community agencies. You can also download an application from the Ministry website, or call Service Ontario. Website and phone numbers are listed at the end of this web page.
For more information about the Trillium Program, contact www.health.gov.on.ca/en/public/programs/drugs/programs/odb/opdp_trillium.aspx
Medical experts will then review the request and will decide whether or not to approve coverage. If you are approved, you may need to pay a part of the cost of the medications.
If a medication is not covered by the Ontario Drug Benefit, you may wish to write or call your local MPP or the Minister of Health to express your need for access to that medication. To find the name, address and telephone of your MPP call Elections Ontario at (416) 326-6300 or 1-800-677-8683 or visit http://www.electionsontario.on.ca It is still possible to request coverage through the Exceptional Access Program (EAP).
Exceptional Access Program (EAP)
This Ontario program facilitates patient access in exceptional circumstances to drugs not funded by the Ontario Drug Benefit, or where no listed alternative is available. To make this request, your physician must send:
- A letter, asking for coverage for a specific time period for a drug not usually covered under the Ontario Drug Benefit.
- Important medical information, including reasons why other drugs covered by the Ontario Drug Benefit can’t be used.
If your child or teen is being treated at a hospital clinic, a hospital social worker may be able to help. The Ministry will still consider your request. Your doctor can still send in the ‘Section 8’ claim for a non-Ontario Drug Benefit drug, but should state that you’re in the process of applying for the Ontario Drug Benefit or Trillium. This will save time as the application process and the Section 8 claim process can go on at the same time.
Explain to your doctor that you are having trouble with medication costs. Your doctor may be able to switch to less expensive medications.
Infoline at 1-866-532-3161 (Toll-free in Ontario only) TTY 1-800-387-5559.
In Toronto, TTY 416-327-4282
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Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from your health provider. Always contact a qualified health professional for further information in your specific situation or circumstance.
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Date of Last Revision: Dec 20, 2013