9.8 - Drug Benefits

Summary of Legislation

The cost of drugs prescribed by an approved health professional for members of the ODSP benefit unit are covered if the drugs have been approved by the Ministry of Health and Long-Term Care (MOHLTC) and purchased from a dispensary during any month in which the person requiring the drugs is a member of the benefit unit.

A non-compliant adult dependant may be eligible for drug benefits, if that person has a serious illness or health condition and would otherwise be financially eligible for income support.

Legislative Authority

Section 44(1)1.ii of the ODSP Regulation

Summary of Directive

ODSP recipients and members of the benefit unit receive a monthly drug card that covers the cost of prescription drugs listed in the Ontario Drug Benefit (ODB) Formulary.

Intent of Policy

To ensure that eligible members of the benefit unit are provided with drug coverage.

Application of Policy

he ODB program covers the cost of prescription products listed under the ODB Formulary. The program is administered by MOHLTC.

In addition to ODSP recipients and Ontario Works participants, the following people are eligible for drug coverage under the ODB program:

• People 65 years of age and older;
• Residents of long-term care facilities;
• Residents of Homes for Special Care;
• People receiving professional services under the Home Care program;
• People in receipt of ODSP Income Support who reside in an institution where drug coverage is not being provided by the institution;
• Trillium Drug Program recipients;
• ODSP recipients, their spouses and dependent children who are eligible for the Extended Health Benefit; and
• People who are eligible to receive the Transitional Health Benefit.

A monthly drug card is provided to ODSP recipients and members of the benefit unit that covers the cost of prescription drugs listed in the ODB Formulary.

Drug cards are mailed with the monthly entitlement cheque/statement and provide drug benefits for the following month. The card lists the names of each eligible member of the benefit unit.

Where an adult dependant who has participation requirements under Ontario Works is removed from the ODSP recipient's benefit unit because of non-compliance, they can continue to receive a drug card if they have a serious health condition or illness and if they would otherwise be financially eligible for ODSP Income Support.

If a valid drug card is not automatically issued with the monthly entitlement cheque/ statement and the member of the benefit unit is determined eligible for the ODSP Drug Benefit, a manual drug card can be issued.

The monthly drug card provides the pharmacist with verification that the person is eligible for coverage under the ODB. The drug card should be presented along with the prescription to the pharmacist.

People eligible for the ODB may be required to pay a co-payment of up to $2 per prescription. This amount is not covered by the ODB or ODSP.

A physician may request coverage for drugs that are not listed in the formulary. MOHLTC has a process (known as "Section 8") where a committee of experts reviews these requests and recommends to MOHLTC whether the ODB should pay for these drugs.

Questions regarding the Section 8 process, as well as inquiries about the ODB and the Formulary, should be directed to MOHLTC's Drug Programs Branch at 416-327-8109 or the MOHLTC INFOline at 1-800-268-1154.

Trillium Drug Program

Trillium Drug Program benefits are available to individuals and families who have high drug costs relative to their income. ODSP recipients who exit and are not eligible for Extended Health Benefit or the Transitional Health Benefit should be referred to the Trillium Drug Program. In order to ensure that people leaving ODSP have their applications processed as quickly as possible, staff should:

• Use the Trillium application form (application kits are available by calling the Ministry of Health and Long-Term Care INFO line at 1-800-268-1154 or in Toronto at 416-314-5518 between 8:30am - 5:00pm or by e-mail at infoline.moh@ontario.ca
• 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 to ensure that the application is completed accurately.

In order to eliminate the potential of time-consuming correspondence in case additional information is required, ODSP staff should include a business card or name and contact information so that they can be contacted if an application is incomplete or if Trillium Drug Program staff have questions about the information in the application.

Normally, applications submitted in this manner will be processed within 48 hours.

Hyperlinks Associated with this Policy Directive

Related Directives:

Bulletins:
2004-09
2006-01

November 2006