December 2016

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 dependent 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.i of the ODSP Regulation

Summary of Directive

To access the ODSP drug benefit, ODSP recipients and members of the benefit unit must present their Ontario health card to a pharmacist along with their prescription. The health card allows the pharmacist to verify that the person is eligible for coverage under the Ontario Drug Benefit (ODB) program.

The ODSP drug benefit covers the cost of drugs listed on the ODB Formulary. The ODB is administered by MOHLTC.

Intent of Policy

To ensure that eligible benefit unit members receive drug coverage.

Application of Policy

All members of the benefit unit are eligible for the ODSP drug benefit. A client may be asked to pay a $2 co-payment for each prescription though many pharmacists waive this fee. This amount is not covered by the ODB or ODSP.

Clients who do not have an Ontario health card may be issued a manual drug card to access the benefit.

A non-compliant adult dependent who has participation requirements under Ontario Works 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.

In addition to ODSP and Ontario Works benefit unit members, the following people are also 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
  • Trillium Drug Program recipients
  • ODSP recipients and members of the benefit unit who are eligible for Extended Health Benefits, and
  • People who are eligible to receive the Transitional Health Benefit

Exceptional Access Program

A physician may request coverage for drugs not listed on the formulary through the Exceptional Access Program (EAP). Requests to the EAP can include cases where drugs on the ODB have been tried and do not work.

Additional information about the EAP is available on the MOHLTC website at: http://health.gov.on.ca/en/public/programs/drugs/programs/odb/opdp_eap.aspx

Information about the EAP and the ODB is also available by calling ServiceOntario:

ServiceOntario Infoline. 1-866-532-3161 or in Toronto at (416) 314-5518
TTY . 1-800-387-5559
TTY in Toronto . (416) 327-4282
Hours of operation. 8:30am - 5:00pm

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 Benefits 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:

  • 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.

In case additional information is required, ODSP staff should include a business card or name and contact information so they can be contacted if an application is incomplete or if Trillium Drug Program staff have questions about the information in the application.
For inquiries regarding the Trillium Drug Program:

Telephone: 416-642-3038
Facsimile: 416-642-3034
Toll-Free: 1-800-575-5386
Text telephone (TTY):   1-800-387-5559
E-mail: trillium@ontariodrugbenefit.ca

Related Directives

2.1 Who is Eligible. Dependent Adults:
9.10 Extended Health Benefits
9.19 Transitional Health Benefit