January 2018

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.

Legislative Authority

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

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).

Under OHIP+:

  • 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, must present their Ontario health card to a pharmacist along with their prescription.

Members of the benefit unit who do not have OHIP coverage will continue to be issued a monthly drug card with their month end statement or will need to inform their caseworker so they can receive a manual drug card.

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 years of age.

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 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 the 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

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:
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: http://www.mcss.gov.on.ca/documents/en/mcss/social/directives/odsp/income_Support/2_1.pdf

9.10 Extended Health Benefits
http://www.mcss.gov.on.ca/documents/en/mcss/social/directives/odsp/income_Support/9_10.pdf

9.19 Transitional Health Benefit
http://www.mcss.gov.on.ca/documents/en/mcss/social/directives/odsp/income_Support/9_19.pdf