Getting HIV Meds
An Overview of Publicly-Funded Plans in Ontario
Both Canada and Ontario have a variety of public plans. Not all of them are listed here. It is important to consult a professional or community organization with experience in this field to look at your needs in order to maximize coverage, especially when you consider that some public plans can be used together with private plans. See our referral section to ensure you understand the variety of public plans available to you. If you need further help with this, contact ACT at 416-340-3470 or firstname.lastname@example.org.
Provincial Drug Plans in Ontario
The province has many plans, but these four are likely the most relevant for those needing prescription medications:
Ontario Disability Support Program (ODSP)
The ODSP supports people with disabilities, and extends prescription drug coverage through the user’s health card. You are still required to pay the pharmacy’s dispensing fee out-of- pocket. Not all pharmacy dispensing fees are the same, and some pharmacies will waive the fee under specific circumstances.
Ontario Works (OW)
Ontario Works provides support for people with no income, and extends prescription drug coverage through the user’s health card. You must pay the pharmacy’s dispensing fee out-of-pocket.
Ontario Trillium Drug Plan
This plan was put in place to address expensive prescription drug costs for people who qualify for Ontario Health Insurance (OHIP) and are challenged by a chronic health condition but are not covered by ODSP or OW.
The Trillium Drug program does not cover all the costs. It is a catastrophic drug program designed to help working people afford drug coverage. It operates by:
1. determining your individual income;
2. calculating a deductible based on that income; and
3. dividing the deductible into four parts – each part paid by you quarterly (August – October, November to January, February to April, and May to July), before the fund pays the rest of the drug costs. “For most people, the deductible for the Trillium Drug Program equals about 3 to 4% of the household income after taxes.”
Note: To determine your income, you need to have filed your taxes for the previous tax year – specifically they look at the amount shown on line 236 of your Notice of Assessment from the Canada Revenue Agency (CRA). To see what your Trillium Drug Plan deductable would be, click here.
Once approved, inform your pharmacy that Trillium covers you when paying the deductible up-front at the pharmacy, and provide your valid OHIP card. The pharmacy will only charge you their dispensing fee.
Ontario Seniors Drug Benefit
After turning 65, residents of Ontario with a valid health card are entitled to prescription drug coverage for drugs approved under the Ontario Drug Benefit Formulary (ODB Formulary). Some people will already be receiving coverage if they have enrolled in the programs mentioned above.
Ontario Drug Benefit Formulary: Which Medications Are Covered?
The Ontario Drug Benefit (ODB) Formulary lists which medications are covered by all four programs described above. Other Ontario healthcare programs that involve your enrolment in a long-term care home, home for special care, or home hospice program also provide coverage as determined by the by the ODB Formulary. You can search for the drug’s “DIN” number, brand name or generic name here: https://www.formulary.health. gov.on.ca/formulary/
Federal Drug Plans
These are a few of the larger federal plans:
Canadian Armed Forces
Canadian Armed Forces personnel are entitled to receive medical care, including medication coverage, from the Canadian Armed Forces. This coverage includes using Truvada for HIV prevention (PrEP). See the list of covered drugs go to: http://www.cmp-cpm.forces.gc.ca/hs/en/drug-benefit-list/index.asp. For more information on medical and dental benefits see: http://www.forces.gc.ca/en/caf-community-health-services-benefits-drug-coverage/index.page.
Coverage for First Nations and Indigenous People
Many indigenous people in Canada can have medications covered through the Non-Insured Health Benefits (NIHB) program. Eligibility for coverage for indigenous people is extended to:
• A registered Indian as per the Indian Act; and
• An Inuk recognized by one of the Inuit Land Claim organizations. This coverage includes using Truvada for HIV prevention (PrEP).
If you qualify under one of the above groups, and you are entitled to receive benefits from another healthcare plan (i.e. public or private), you must submit your claims to these plans prior to submitting them to the NIHB program. If you are not successful in securing coverage through those plans, then you may access coverage through NIHB. See more details about this here: https://www.canada.ca/en/health-canada/services/first-nations-inuit-health/non-insured-health-benefits/benefits-information/non-insured-health-benefits-nihb-program-general-information-questions-answers-first-nations-inuit-health-canada.html1
Health Coverage for Refugees and Refugee Claimants
The Interim Federal Health Program (IFHP) provides limited, temporary coverage of healthcare benefits to people in the following groups who aren’t eligible for provincial or territorial health insurance:
• protected persons, including resettled refugees;
• refugee claimants; and
• certain other groups.
This coverage includes antivirals for HIV treatment and using Truvada for HIV prevention.2