Paying for PrEP in Ontario

Paying out of pocket, or getting assistance with PrEP costs has never been easier in Ontario. It’s now possible to get PrEP without paying anything out of pocket or at a significantly reduced price.

Here are the options to consider:

Public Insurance Plans

There are several Ontario and Canadian public plans that cover the cost of PrEP. This includes: federal plans provided to Canadian First Nations peoples, people with refugee status, and Canadian Armed Forces personnel. Talk to a pharmacist or your doctor for more information.

Additionally, PrEP is now listed on Ontario’s Drug Formulary. This means that it is available 100% free of charge to those registered with Ontario Works and the Ontario Disability Support Program (ODSP). If you are not eligible to be enrolled in these programs you may still qualify for some coverage under Ontario’s Trillium Drug Plan.

To find out more about the public insurance plans see our Undetectable Viral Load page. Many of the federal drug plans do cover PrEP. Ontario will cover PrEP on its public drug plans, although this will require some sort of co-pay.

Learn more here, or contact ACT for guidance at: 416-340- 8484 ext 234 or onlineoutreach@actoronto.org.

OHIP+ prescription drug coverage for youth 24 and under will no longer be universal beginning on April 1, 2019

OHIP+, which began on January 1, 2018, currently provides free prescription drug coverage for all Ontario youth age 24 and under who have OHIP coverage. With the child/youth’s OHIP health card or health care number, pharmacies fill prescriptions for people 24 and under without any charges, dispensing fees, co-payments or deductibles. People age 24 and under are automatically covered by OHIP+, with no requirement to enroll or register. OHIP+ fully covers the cost of more than 4,400 drug products that are currently available through the Ontario Drug Benefit program.

Beginning on April 1, 2019, OHIP+ will no longer be universal:

• OHIP+ will continue for people age 24 and under who do not have private insurance.

• People age 24 and under who receive Ontario Works/Ontario Disability Support social assistance or home care, or who are residents in certain care homes will be eligible for the Ontario Drug Benefit program without any deductibles or co-payments, whether they have access to private insurance drug coverage or not.

 

People age 24 and under who are in any way captured by private insurance drug coverage will no longer have any drug coverage under OHIP+. It does not matter whether the private insurance covers the drug(s) prescribed, or if there are deductibles, co-payments or other limits. If they or their families are left with significant prescription drug costs that are not covered by the private insurance, they can access the Trillium Drug Program.

Private Plans

First consider if you can use a public plan, possibly even in conjunction with a private plan. You or your partner may have an insurance plan with drug benefits that you may not be using, but could access. Many people may not have their own policy, but may have some form of coverage through their partner or another family member.

Read over your insurance benefits policy. Look for drug coverage, which is usually listed as “extended healthcare benefits”. See our Private Insurance Worksheet for guidance.

Once you read your plan, understand the limits of your drug coverage. Write them out in plain language and note the page and paragraph where it is found. It is easy to forget this information. Noting it will save you a great deal of time searching for it again.

Examples of limits in a policy:

– There may be a lifetime expense limit, or maximum expense limit for a specific time, such as a year.
– There may be refill limitations in place. This restricts how often you can refill a prescription in a given period of time.
– The policy you have might only cover the cost partially, such as 60% of drug costs. It is rare that you will have a plan that covers 100% of drug costs. Even partial coverage makes PrEP more affordable; for example, paying $100 a month (because the insurance plan pays 75% or $300) for the medication is much better than paying $400!

There are likely to be other qualifying basic criteria for drug coverage such as: “…only on a prescription,” “when prescribed by a physician…” or “…dispensed by a pharmacist, physician…” This is standard in almost all plans.

Pharmacies

While PrEP can be expensive, the cost can vary from pharmacy to pharmacy. It might help to shop around for pricing before deciding on where you want to get it.

For more information see: Private Insurance for PrEP.