Access to Antipsychotic Medications
How Do Medications Become Available In Ontario?
Drug Plans In Ontario
Other Drug Plans
How Do Medications Become Available In Ontario?
The first step for medications to become available is for them to be approved by Health Canada. In this step, which can take several years, Health Canada evaluates the medication to make sure it works and that it is safe.
Once a medication is approved by Health Canada, the pharmaceutical company that discovered it can sell the medication in Canada. However, it is also important that medications are accessible to Canadians from a cost perspective. To determine this, there are two separate processes – at federal and provincial/territorial levels – in addition to the approval by Health Canada.
Private Insurance Plans
To help Canadians afford medications, they are often covered by different types of insurance. Many full-time employees in Canada have private insurance that covers part or all their medication costs. Each private insurance company creates its own list of what medications they will cover on their plan and what amount (if any) you will have to co-pay. They also determine what conditions or illnesses are eligible for coverage. The cost and coverage criteria are set by the insurance company and may be different depending on where you are employed and who your insurance provider is. Your pharmacist is not involved with determining these costs. The amount they charge you is based on the claim they submit to your insurance company on your behalf for your prescribed medication.
Public (Provincial) Insurance Plans
Older people, people who live in long-term care facilities, people with disabilities, or those with lower incomes, may have their medication costs partially or wholly covered by a number of provincial insurance plans.
The medications that are reimbursed by the provincial insurance plans must be listed on the Ontario Drug Benefit Formulary. The approval process for a medication to be listed on the formulary can take many months, even years. The decision about whether to list a medication is based on many factors, including cost, and how well the medication works compared to others that are already available.
Medications Available in Other Countries
Sometimes medications are approved for sale in other countries before Canada. Therefore, you may see advertisements for medications available in the United States on television or in magazines. You may also have lived in another country and been receiving a medication there that is not available in Canada. It is important to check with your doctor or pharmacist to determine what is available in Canada. In many cases medications approved in other countries do come to Canada, but it can take time. Doctors in Canada can only prescribe medications approved by Health Canada, so it is important for them to know if you have been receiving something in another country that is not available. It is not a good idea to order medications over the internet from other locations as you cannot be sure of their quality and safety
What Is The Ontario Drug Benefit Formulary?
The formulary is a list of approved prescription medications (both generic and brand name products) available in Ontario. It sets the provincial standard for price and quality, and decides what generic medication products can be exchanged for brand name products.
Drug Plans in Ontario
The costs of many antipsychotic medications are covered through various provincial insurance plans in Ontario: Ontario Drug Benefit Program, Exceptional Access Program, Trillium Drug Program, and Special Drugs Program. More information about medication coverage can be found on the Ontario Ministry of Health and Long-Term Care’s website. It is a good source of helpful information, application forms and contact numbers.
Please note that to be eligible for coverage under many of these plans, it is necessary to be an Ontario resident with valid Ontario Health Insurance Plan (OHIP) coverage.
Ontario Health Insurance Plan (OHIP)
Most people living and/or working in Ontario are eligible for OHIP. If you are new to Ontario, you must apply for OHIP coverage. There is a 3-month waiting period for OHIP to start, so you should apply as soon as you arrive. In order to receive OHIP you must be a Canadian citizen, permanent resident or among one of the newcomers to Canada groups who are eligible for OHIP as set out in Ontario’s Health Insurance Act. In addition, you must be in Ontario for 153 days in any 12-month period and Ontario must be your primary place of residence.
Ontario residents need a health card that entitles them to healthcare services provided by OHIP. OHIP covers all medically-necessary services covered by physicians. However, OHIP does not cover the costs of prescription medications unless you are hospitalized. All in-patient medications are covered by OHIP. Once discharged from the hospital, you will need a form of insurance to pay for your medications and/or you may need to pay for them yourself.
In June 2018, the government announced that OHIP+ will move to provide medication coverage for children and youth who are covered by OHIP and aged 24 and under who are not covered under a private plan. Children and youth who are not covered by private benefits will continue to receive eligible prescriptions for free. Those who are covered by private plans will bill those plans first, with the government covering all of the remaining eligible costs of the prescription. This change will come into effect on April 1, 2019. More information can be found on the Ontario Ministry of Health and Long-Term Care’s website and the OHIP+ website.
Ontario Drug Benefit Program (ODB)
The ODB provides coverage for most of the cost of medications listed on the Ontario Formulary. If you are eligible to receive benefits from the ODB, you may still need to pay a small fee for a prescription.
If the medication prescribed is not listed on the Ontario formulary, a special funding request can be submitted through the Exceptional Access Program (EAP)
, which handles such funding requests on a case-by-case basis. This includes cases where medications on the ODB list have been tried and do not work or where an alternative medication is not available through ODB. The funding request is usually prepared by a pharmacist or a physician, however it must be submitted by a physician. The response is faxed to the physician with an approval or a rejection for coverage. If approved, the form must be sent to the community pharmacy for their files and to ensure they can submit the claims to the government for coverage.
If you are an Ontario resident with a valid Ontario health card, you are eligible for ODB coverage if at least one
of the following statements applies:
- You are older than 65 years of age.
- You live in a long-term care home or home for special care, or you are receiving professional homecare services.
- You have high medication costs relative to your income and are registered in the Trillium Drug Program.
- You are on Ontario Disability Support Program and/or Ontario Works.
Trillium Drug Program (TDP)
This plan is for residents of Ontario who have a valid OHIP card and who have high prescription medication costs in relation to their net household income.
Trillium provides coverage for prescription medication products that are listed on the ODB formulary. To register for this program, all
the following must apply:
- You have a valid Ontario health card and are a resident of Ontario.
- You are not eligible for medication coverage as another category recipient under the Ontario Drug Benefit Program (i.e., you are not a senior over 65 years of age; you are not a social assistance recipient; you are not receiving professional homecare services, and you are not a resident of a long-term care home or home for special care).
- You do not have private insurance that covers 100% of your prescription medication costs.
Only eligible medication costs count towards the TDP deductible or are covered as program benefits. To ensure coverage under the program, check with a pharmacist or healthcare provider to make sure your prescriptions fit into one
of the following categories:
- They are listed on the ODB formulary/Comparative Drug Index.
- They are on the Facilitated Access List of HIV/AIDS medications.
- They have been approved for coverage through the ministry’s Exceptional Access Program.
What Costs Will I Pay?
Under the TDP you will pay two different fees each year:
- You will pay a set amount of your prescription medications costs each year. This amount is called your “deductible”. The amount of your deductible is based on your household income (usually around 4% of your household’s combined net income). The deductible you have to pay is divided into 4 equal amounts over the year starting on August 1st. As you fill prescriptions, the cost for eligible medications will count towards your deductible. Once the deductible is paid, the ODB program will pay for most of the cost of your medications.
- After you pay your deductible, you may be asked to pay up to $2 for each prescription that ODB covers. This is called a co-pay. Some pharmacies charge this co-pay, however many are currently waiving this fee.
Special Drugs Program
The Special Drugs Program covers the full cost of certain outpatient medications used in the treatment of specific illnesses. If you meet all
the following criteria, your medication costs are covered through this program:
Please note that clozapine is the only antipsychotic medication covered under the Special Drugs Program
- You are an Ontario resident with a valid Ontario health card.
- You have one of the diseases or conditions covered (including schizophrenia).
- You meet the established clinical criteria.
- You are approved for clozapine.
Other Drug Plans
Non-Insured Health Benefits (NIHB) Program
The Non-Insured Health Benefits (NIHB)
Program is a national benefit program that provides benefit claims for medications, dental care, vision care, medical supplies, mental health crisis counselling and other important health services for eligible First Nations people and Inuit.
The NIHB program covers prescription medication products and some over-the-counter products listed in the NIHB Drug Benefit List.
To access medication coverage through this program, you must be eligible. An eligible recipient is defined as a resident of Canada and one of the following:
- A registered First Nations person (status) according to the Indian Act.
- An Inuk recognized by one of the Inuit Land Claim organizations.
- An infant less than a year of age, whose parent is an eligible recipient.
If you are eligible for benefits under another private insurance plan or public health or social program, claims must first be submitted to these plans and programs prior to the NIHB program.
Interim Federal Health Program
The Interim Federal Health Program (IFHP)
provides limited temporary coverage of healthcare costs to protected persons who are not eligible for provincial health insurance plans and where a claim cannot be made under private health insurance. The program is paid for by Immigration, Refugees and Citizenship Canada. A protected person may include any of the following:
- Resettled refugees
- Refugee claimants
- Certain persons detained under the Immigration and Refugee Protection Act
- Victims of human trafficking
- Certain other groups
The coverage provided to individuals through this program is similar to health coverage provided to Ontario citizens. The level of coverage is similar to those who are receiving social assistance. This program acts like a bridging program to provide services until the individual becomes eligible for provincial health insurance.
Under this program eligible individuals will be covered for hospital services, services of a doctor or registered nurse, laboratory, diagnostic and ambulance services. In addition, individuals receive coverage for prescription medications and some other pharmacy products; limited dental and vision care; prosthetics and devices to assist mobility; psychological counselling; and post-arrival health assessments.
In order to receive coverage under this program you must show your Interim Federal Health Program eligibility document to your healthcare provider.
For more information on eligibility and coverage please go to the following website:
For More Information On Drug Plans in Ontario
Please visit this website
for detailed information on all the available provincial health plans and programs; specifically, information on reimbursement for prescription medications in Ontario under the following programs:
- Private Insurance/Third Party Insurance
- Ontario Drug Benefit Program/Trillium Drug Program
- Non-Insured Health Benefits Program
- Veterans Affairs Canada
- Public Service Health Care Plan
- Interim Federal Health Program
- Correctional Service Canada