Who can qualify
You will qualify for the Ontario Drug Benefit (ODB) program when you turn 65 years old. You will qualify before you reach that age because you’re:
- living in a:
- long-term care home
- home for special care
- Community Home for Opportunity
- 24 years of age or younger and not covered by a private insurance plan
- receiving professional home and community care services
- receiving benefits from Ontario Works or Ontario Disability Support Program
- enrolled in the Trillium Drug Program
For seniors (people 65 years and older), we will send you a letter about three months before your 65th birthday to let you know you will automatically join the Ontario Drug Benefit program on the first day of the month after you turn 65 years old.
If you are a low-income senior or a senior couple with income below certain thresholds, you can have your Ontario Drug Benefit deductible waived and co-payment fees reduced to $2 by applying for the Seniors Co-Payment Program. The Ontario Drug Benefit program is forOntario residents onlyand prescriptions must befilled in an Ontario pharmacyto be covered. Make sure your Ontario health card is valid (for example, it hasn’t expired). Your pharmacist will need your health card to confirm your eligibility for the Ontario Drug Benefit program.
What’s covered
The Ontario Drug Benefit program coversmost of the cost of approximately 5,000prescription drug products.
Search for covered drugs
It also helps you pay for:
- allergy shots and epinephrine injectable products (used in response to severe allergic reaction)
- some products used in monitoring and testing for diabetes
- some prescribed over-the-counter drugsunder specific circ*mstances
- some nutrition products
- some drugs used in the treatment ofHIV/AIDS
- some drugs used in palliative care
- some drugs to help quit smoking
Allergy shots and epinephrine injectable products
The Ontario Drug Benefit program covers 100% of the cost of your allergy shots and epinephrine injectable products (for example, auto-injectors), which are used in response to severe allergic reactions.
When you go to the pharmacy to get:
- allergy shot medication, you need a prescription AND a Special Authorization Allergen form from your doctor or nurse practitioner
- epinephrine auto-injector(s), you ONLY need a prescription from your doctor or nurse practitioner (you do not need a Special Authorization Allergen form)
Antihistamines and mixtures used in testing for allergies are not covered by the ODB program.
Diabetes products
Some products used to monitor and test for diabetes are covered by the Ontario Drug Benefit program.
This includes diabetic testing strips for measuring blood glucose (sugar) – a common product prescribed by doctors or nurse practitioners to patients living with diabetes.
Diabetic testing strips
The Ontario Drug Benefit program covers the cost for a maximum number of diabetic testing strips based on your current treatment method and clinical guidelines set by the Diabetes Canada.
This table shows the type of treatment and number of test strips covered.
| Patients managing diabetes | Maximum number of strips (per year) covered |
|---|---|
| with insulin | 3,000 |
| using medication with higher risk of causing hypoglycemia (low blood sugar) | 400 |
| using medication with lower risk of causing hypoglycemia (low blood sugar) | 200 |
| through diet/lifestyle therapy only (no insulin or medications used) | 200 |
If you want more than the maximum quantity of strips, please see your physician or pharmacist.
Qualifying for other programs
Syringes, lancets, glucometers and other diabetic suppliesare not coveredby theODBprogram. However, other programs may help you pay for products.
Find out if you qualify for other coverage through:
- Assistive Devices Program (ADP)
- Ontario Disability Support Program (ODSP)
- Ontario Works (OW)
- Diabetes Canada
Over-the-counter drugs
Some drugs can be purchased without a prescription (also called over-the-counter drugs), if you pay for them yourself. The Ontario Drug Benefit Program may cover the cost of these drugs but only if your physician or nurse practitioner gives you a prescription for them and if the drugs are either:
- listed on the ODB formulary
- covered through the Exceptional Access Program (EAP)
For the Exceptional Access Program to cover an over-the-counter drug:
- you must meet the EAP program criteria
- your doctor or nurse practitioner must send us a request for coverage
- we must approve the request
If you think that the cost of an over-the-counter drug should be covered, check with your healthcare provider before buying the drug to avoid out-of-pocket costs.
Nutrition products
The Ontario Drug Benefit program covers the cost of nutrition products up to a maximum dollar amount. The product must be your sole source of nutrition and be prescribed by your doctor or nurse practitioner.
Besides writing you a prescription, your doctor or nurse practitioner must fill out a Nutrition Products form for you to receive coverage, stating that the product is the sole source of your nutrition.
The Ontario Drug Benefit program does not cover the cost of a nutrition product if you’re able to eat some solid foods, as noted by your doctor or nurse practitioner. It also does not cover a nutritional product used for:
- supplementing other foods
- weight loss (even if directed by a doctor or nurse practitioner) to treat obesity
- managing food allergies
- bodybuilding
- voluntary meal replacement
- feeding infants with normal digestive functions
Drugs used to treat HIV/AIDS
Many drugs used to treat HIV/AIDSare covered by the Ontario Drug Benefit program for eligible Ontarians as a General Benefit and some drugs require a prescription by a physician who is registered on the ministry’s Facilitated AccessHIV/AIDS Physician list. If you require any further information regarding the ministry’s Facilitated Access lists, please contact your prescriber.
Drugs used in palliative care
The Ontario Drug Benefit program covers some drugs used in palliative care (for example, higher strength narcotic drugs for pain). The drugs must be:
- prescribed by a doctor or nurse practitioner on the Palliative Care Facilitated Access List
- listed in the official Ontario Drug Benefit Formulary, Part VI-B: Facilitated Access to Palliative Care Drug Products
If your doctor or nurse practitioner is not registered on the Palliative Care Facilitated Access List, the drugs may still be covered if your doctor or nurse practitioner submits a coverage request to the Exceptional Access Program either by fax or by calling the Exceptional Access Program’s telephone request service. Note that you will also need to consult with a doctor or nurse practitioner who is registered on the Palliative Care Facilitated Access List if you are requesting a high strength opioid through the Exceptional Access Program, including the telephone request service.
Drugs to help quit smoking
The Ontario Drug Benefit program covers:
- up to a year of pharmacist-assisted counselling (talk to your pharmacist or health care provider)
- drugs for treatment if you are age 18 years or older
What’s not covered
The following will not be covered by the Ontario Drug Benefit program:
- prescription drugs that you buy outside Ontario
- drugs that are not listed on the official Ontario Drug Benefit Formulary/Comparative Drug Index, or are not approved by the Exceptional Access Program
Brand-name vs. generic drugs
When you search to check if a medication is covered, you may see that what you searched for is “equivalent to” another medication. One is the “brand" name and the other is “generic.”
When a company develops a new drug, it will have the sole right to make (based on a formula) and sell the drug (under a brand name) for a certain period of time. That’s called a patent.
When the patent ends, other companies are allowed to make and sell their own version of the drug. These are called generics and usually cost less than brand-name drugs, but they are tested and proven to work in the same way.
You can get covered foreither the brand-name or the generic drug, whichever costs less. This means coverage is generally for the generic product with some exceptions, such as:
- when a generic is not available or not yet approved for coverage under theODBprogram, even though it’s available on the market (for example, the manufacturer of a generic drug has not submitted it to the ministry for approval as interchangeable with a brand-name drug)
- when you have had adverse reactions to at least two generics
Adverse reactions to generic drugs
If you’ve had bad reactions to at least two generics, the ODB program covers the brand-name drug. In this case, your prescriber:
- fills out the Side Effect Reporting Form (PDF that you can print and take on your next visit to your prescriber)
- writes no substitution on your prescription
Once filled out by your prescriber, take the form and prescription to your pharmacist. Your pharmacist submits the completed form to Health Canada, which monitors drug safety.
Limited Use drugs
If you search for a drug and it’s labelled as "Limited Use," that means it is covered only under special medical circ*mstances.
When you’re prescribed one of these drugs, your doctor or nurse practitioner must confirm that your circ*mstances require treatment with a Limited Use drug by writing a three-digit code on your prescription, called the Reason for Use code.
If you’re given a refill by your doctor or nurse practitioner, ask to make sure it’s still available for Limited Use treatment. Some Limited Use drugs are covered for a maximum number of days or weeks or years, while some are approved for lifetime coverage. You could also ask your pharmacist to check.
Biologic vs. biosimilar drugs
Biologics
Biologics are medicines made from substances found in living things. They are often used to treat diseases such as:
- cancer
- immune system disorders
- diabetes
Biosimilars
A biosimilar drug is a highly similar version of a biologic drug. When a company develops a new biologic drug, that company has the sole right to make and sell the drug for a certain period of time. After that period ends, other companies can start producing their own version of the biologic drug. The version of the biologic drug that other companies produce is the biosimilar drug.
Patients and health care providers can be confident that the quality, safety and patient benefits of the biosimilar are highly similar to the biologic drug. Biosimilars undergo the same robust and rigorous approval process by Health Canada and to be approved in Canada, a biosimilar must be proven to be highly similar, with no clinically meaningful differences in terms of safety and efficacy.
Coverage
As of December 29, 2023, the ODB program will no longer cover:
- Remicade® (infliximab)
- Enbrel® (etanercept)
- Lantus® (insulin glargine)
- Rituxan® (rituximab)
- Humalog® (insulin lispro)
- Humira® (adalimumab)
- NovoRapid® (insulin aspart)
- Copaxone® (glatiramer)
If you’re taking any of these medications, you may need to transition to the biosimilar drug for ODB program to cover the cost. Speak to your doctor or nurse practitioner about this change during the transition period, beginning March 31, 2023.
Exemptions will be considered for patients in certain clinical circ*mstances on a case-by-case basis in consultation with their health care provider under the Exceptional Access Program.
If you’re taking another biologic not listed above, it will still to be covered under the ODB program.
Why coverage for biologic drugs is changing
Patients will continue receiving the same high-quality treatment, while allowing the government to fund more new drug therapies, bring innovation to the health care system and continue its work to deliver better, connected patient care.
Ontario is the eighth jurisdiction in Canada to implement biosimilars transition policy, joining British Columbia, Alberta, New Brunswick, Quebec, Northwest Territories, Nova Scotia and Saskatchewan, where thousands of patients have safely transitioned to a biosimilar version of their medication.
Resources
- Information from the Arthritis Consumer Experts
- Canadian Digestive Health Foundation’s video about biosimilars
- Ontario.ca/biosimilars
What you pay
What you pay depends on how you qualify for the Ontario Drug Benefit program:
- Seniors
- 24 years of age or younger and not covered by a private insurance plan
- Living in a long-term care home, home for special care or a community home for opportunity
- Receiving professional home and community care services
- Receiving benefits from Ontario Works or Ontario Disability Support Program
- Enrolled in the Trillium Drug Program
Seniors
With the Ontario Drug Benefit program, as a senior (someone 65 years or older) you pay a portion of prescription-drug costs based on your annual income and marital status. You can get coverage as a single senior (including as a widowed spouse) or as a couple (includes spouses who are married, same-sex or common-law partners).
To apply
Choose the group you belong to, to find out what you pay:
- Single senior with income above $25,000
- Senior couple with combined income above $41,500
- Single senior with income of $25,000 or less
- Senior couple with combined income of $41,500 or less
Single senior with income above $25,000
A single person aged 65 years or older with a yearly income above $25,000 after deductions pays:
- the first $100 of total prescription costs each program year (August 1 to July 31 the following year)
- this is called the deductible and is paid down when you fill your prescriptions
- after paying the deductible, up to $6.11 for each prescription, filled or refilled
- this amount is called the co-payment
How it works
We will send you a letter aboutthree months beforeyour 65thbirthday to let you know you will automatically join the Ontario Drug Benefit program. This is agood time to tell your doctor, nurse practitioner and pharmacistso they can plan ahead to make sure that, when needed, you are prescribed one of the more than 5,000 drugs approved for coverage.
Then, go to your pharmacy on the first day of the month after you turn 65 years old (for example, if you turn 65 on April 15, go on May 1). This is yourofficial start datein the Ontario Drug Benefit program.
Don’t forget your Ontario Health card to show the pharmacist.
Senior couple with combined income above $41,500
For a couple (where at least one person is aged 65 or older), with a combined yearly income above $41,500
- the first $100 per person of total prescription costs each program year (August 1 to July 31 the following year)
- this is called the deductible and is paid down when you fill your prescriptions
- after paying the deductible, up to $6.11 for each prescription that is filled or refilled
- this amount is called the co-payment
Only a spouse who is a senior receives drug benefits as a senior. A spouse who is under 65 years can apply to, or remain enrolled in the Trillium Drug Program.
How it works
We will send you a letter aboutthree months beforeyour 65thbirthday to let you know you will automatically join the Ontario Drug Benefit program. This is agood time to tell your doctor, nurse practitioner and pharmacistso they can plan ahead to make sure that, when needed,you are prescribed one of the more than 5,000 drugs approved for coverage.
Then, go to your pharmacy on the first day of the month after you turn 65 years old (for example, if you turn 65 on April 15, go on May 1). This is yourofficial start datein the Ontario Drug Benefit program.
Don’t forget your Ontario Health card to show the pharmacist.
Calculating first-year deductible
For your first year of Ontario Drug Benefit program eligibility, depending on the month you turn 65, the deductible may be lower than $100.
That’s because the amount of the deductible is based on the number of months between your official start date (the first day of the month after you turn 65) and July 31 (the last day of the Ontario Drug Benefit program year).
For example, if you turned 65 on April 15, your official start date would be May 1. Counting from May 1 to July 31 your deductible for the first year would be $25.
Use this chart below to see what the deductible will be in your first year:
| Month you were born | Amount of first-year deductible |
|---|---|
| July | $100.00 |
| August | $91.67 |
| September | $83.33 |
| October | $75.00 |
| November | $66.67 |
| December | $58.33 |
| January | $50.00 |
| February | $41.67 |
| March | $33.33 |
| April | $25.00 |
| May | $16.67 |
| June | $8.33 |
Living in a long-term care home, home for special care or community home for opportunity
If you live in one of these homes, you are automatically covered by the Ontario Drug Benefit program. Youpay up to $2for each drug filled or refilled (unless you live in a long-term care home where the co-pay is zero) – and youdo nothave to pay a deductible.
For those who are aged 24 years and under and are living in one of these homes, youdo nothave to pay the $2 for each drug filled or refilled, even if you have private insurance.
Ask yourcare coordinatoror pharmacist how it works.
Receiving professional home and community care services
If you are receiving professional home and community care services arranged through Ontario Health atHome, you are automatically covered by the Ontario Drug Benefit program. Youpay up to $2for each drug filled or refilled – and youdo nothave to pay a deductible.
If you are aged 24 years or under and are receiving professional home and community care services, youdo nothave to pay the $2 for each drug filled or refilled.
Ask yourcare coordinatoror pharmacist how it works.
Receiving benefits from Ontario Works or Ontario Disability Support Program
If you receive benefits from one of these programs, you are automatically covered by the Ontario Drug Benefit program. Youpay up to $2for each drug filled or refilled – and youdo nothave to pay a deductible.
If you are aged 24 years and under and are receiving benefits from one of these programs, youdo nothave to pay the $2 for each drug filled or refilled.
Ask yourOntario WorksorOntario Disability Support Programcase worker how it works. Your pharmacist can also tell you.
How to get a refund (reimbursem*nt)
If you were covered by the Ontario Drug Benefit program and paid for acovered drug, submit your receipts online via the Ontario Drug Benefit Program Receipt Submission Form available on the Ontario Drug Benefit Program Online Applications and Forms website.
You will be asked to include:
- your Ontario Health card number
- a copyof the official prescription receipt issued by the pharmacy and signed by a pharmacist (do not submit cash register or credit card receipt or invoices from a doctor office or clinic)
Note: if you’ve lost the official prescription receipt, you can ask the pharmacist to provide you with the Patient Medical Expense Report (PMER) as proof of your prescription receipt document. The PMER must have a pharmacy stamp and pharmacist’s signature and it must contain the same information as an official prescription receipt:
- recipient name and address
- pharmacy name and address
- prescription (Rx number)
- drug name and Drug or Product Identification Number (DIN/PIN)
- dispensing date and quantity
- total amount paid, drug cost and dispensing fee
If you do not have access to a computer, mail the above receipts or PMER, along with your Ontario Health Card number to the appropriate program address below.
If you arein theTrillium Drug Program, mail the documents to:
Trillium Drug Program
Ministry of Health
P.O. Box 337, Station D
Etobico*ke ON M9A 4X3
For any questions you can reach out by:
- telephone:
416-642-3038 (Toronto area) - toll-free:
1-800-575-5386 - email: trillium@ontariodrugbenefit.ca
If you are notin theTrillium Drug Program, mail the documents to the address for Seniors Co-Payment Program recipients and all other Ontario Drug Benefit Program recipients:
Ontario Drug Benefit Program
Ministry of Health
P.O. Box 384, Station D
Etobico*ke ON M9A 4X3
For any questions, you can reach out by:
- telephone:
416-503-4586 (Toronto area) - toll-free:
1-888-405-0405 - email: seniors@ontariodrugbenefit.ca
How to get a three-month supply
Under the Ontario Drug Benefit program, you can request a three-month supply of some drugs used to treat certain chronic conditions, such as:
- diabetes
- high cholesterol
- high blood pressure
Getting a three-month supply of your prescription means you will pay co-payment fees less often.
Talk to your pharmacist to find out which drugs qualify and to learn how to request a three-month supply.
Coverage during travel
For travel in Ontario
Your pharmacist can transfer your prescription to another pharmacy in Ontario, as long as:
- your prescription has enough refills on it
- you’re not refilling it too soon (within 10 days of end of supply)
- your prescription is not for a controlled drug, controlled drug preparation or a narcotic (for example, oxycodone, Dilaudid, Xanax, diazepam)
For travel outside Ontario
If you’re planning to travel outside Ontario, you may be able to get a larger supply, but you can only do this once during the Ontario Drug Benefit program year – between August 1 and July 31. Keep in mind that prescriptions filled outside Ontario are not covered by the Ontario Drug Benefit program.
Here is how it works:
- if you have a supply of less than 30 days, you can get a travel supply ofup to 200 days
- if you have a supply of 30 days or more, you can get a100-day supply
Get a travel supply of medication
To get your supply for travel out of Ontario, give your pharmacist either:
- a letter (that you can write yourself) confirming you’re leaving the province for more than 100 days
- a copy of your travel insurance policy showing you’re leaving the province for between 100 and 200 days
You have to pay the deductible or co-payment amount for the extra supply.
