Understanding The Prescription Drug Insurance Coverage In Canada 

Do you know you can get your prescription drugs free of cost from the federal and provincial governments? Know about the conditions and the different rules associated with “prescription drug insurance coverage” in Canada?  

What Is Prescription Drugs Insurance in Simple Language?  

Let us first understand “prescription drugs.” Whenever you or your family members contract any disease or ailment, you prefer to visit a doctor.  

Next is:  

• Admits you to the hospital and gives your drugs under administration  

Or  

• Recommends certain medicines on a stamped letterhead along with the schedule  

In both these cases, your physician prescribes the drugs you may consume. You may buy and have them. A prescription drugs insurance covers prescribed medicines offered during hospitalization or on a valid prescription by a qualified medical practitioner.   

Under a prescription drugs insurance program, you get reimbursement or upfront cash benefits for all the expenses incurred by you upon the purchase of prescription drugs.   

How Does A Prescription Drugs Insurance Coverage Operate in Canada?  

Prescription drugs insurance in Canada operates at two levels:  

• The first one is at the federal level, which we know as the universal public healthcare system  

And  

• The second one is at the provincial/ territorial level, where different Canadian provinces and territories have developed their own publicly funded drug plans, having their conditions, requirements, and eligibility criteria.  

Let us now understand both these levels.   

1. Universal Public Healthcare System–At Federal Level  

• The universal public healthcare system running and operating in Canada is unique from most developed nations.   
• It covers the cost of only the prescribed drugs provided in the Canadian Hospitals.   
• This system draws its powers from the Canada Health Act, 1984, and states that the federal government will pay for prescription drugs administered to the patients in the hospital. 
• In such a case, the admitted patients will pay nothing towards the cost of prescribed drugs. 
• However, it does not provide insurance coverage for the prescription drugs consumed outside the hospital setting.   

2. Publicly Funded Drug Plans–At Provincial/ Territorial Level  

• The provincial Canadian governments perhaps plugged the drawback of a universal public healthcare system by running and implementing publicly funded drug plans.   
• Each province has its own publicly funded drug plan, which differs in rules and requirements. 
• It primarily states:  
  • What prescription drugs do they cover under the insurance program?  
  • What are the different conditions in which the provincial government bears the cost of prescribed drugs?  
  • Who are the eligible recipients that can enjoy the benefits of such coverage?  
• Typically, publicly funded drug plans intend to help those in need and use different parameters, such as age, income, and medical conditions, to identify the eligible recipients.  

How Does A Publicly Funded Drug Plan Operate in Ontario?  

The province of Ontario runs an “Ontario Public Drug Program” to help its residents by paying most of the cost of prescription drugs. Let us now understand:  

1. The different drug benefit programs in Ontario  
2. Eligibility criteria  
3. The covered prescription drugs and  
4. Some important points to remember  

1. The Different Drug Programs  

The Ontario Drug Benefit (ODB) Program runs two different programs in the province:  

• Trillium Drug Program (TDP)   
• Seniors Co-payment Program (SCP)  

2. Eligibility Criteria for the Ontario Drug Benefit (ODB) Program  

• You are eligible to get the benefits of an ODB program if you are 65 years or older  
• If you are less than 65 years, then still you qualify for the ODB program if:  
• You are living in a:  
  • Long-Term Care Home  
  • Home for Special Care  
  • Community Home for Opportunity  
• You are 24 years old or younger (no private insurance plan will not cover you) 
• You are receiving professional home and community care services  
• You are receiving benefits from   
  • Ontario Works or
  • Ontario Disability Support Program  
• Enrolled in the Trillium Drug Program  

3. The Covered Prescription Drugs  

The Ontario drug benefit program covers over 5000 prescribed drugs. It also covers the cost of the following major medical products: 

S. no.	Covered Drug Products	Requirements	Quantum of Coverage (subject to deductibles and co-payment requirements)
1	Allergy Shots	1. Prescription Special 2. Authorization Allergen Form	100% of the cost
2	Epinephrine Injectable Products	1. Only Prescription	100% of the cost
3.	Diabetic Testing Strips	1. Only Prescription	Up to 3000 strips (the quantum differs for different diabetic patients)
4.	Over the counter drugs	1. Prescription Listed on the ODB Formulary  2. Exceptional Access Program (EAP) covers it	100% of the cost
5.	Nutritional products not used as food supplements, weight loss, managing food allergies, bodybuilding, etc.	1. Prescription Nutrition Products Form	100% of the cost

4. Some Important Things to Remember  

Here is a list of some points:  

• The Ontario Public Drug Program is separate from the Ontario Health Insurance Plan (OHIP) for doctors, health care workers, and other medical providers.   
• All seniors of 65 years or above get an intimation from the provincial authority three months before their 65th birthday. This letter states they will join the Ontario Drug Benefit program after three months.  
• The Ontario drug benefit program is only for the Ontario residents. Further, it also requires filling the prescriptions in any pharmacy in Ontario.  
• The Ontario drug benefit program does not cover the following prescription drugs:  
  • Bought from outside Ontario   
  • Not listed on the Ontario Drug Benefit Formulary/Comparative Drug Index  
  • Not approved by the Exceptional Access Program (EAP)  

What Are Private Prescription Drugs Insurance Policies?  

Besides the federal and provincial/ territorial drug benefit programs, insurance agencies offer private prescription drug insurance.   

These insurance policies cover the cost of your prescribed drugs instead of a premium, which you will be required to pay either monthly or annually.   

Most Canadians prefer to avail the benefits of prescription drug insurance by getting themselves enrolled in both the government-run programs and the insurance policies offered by private companies.   

Prescription drug insurance offered by employers covers several Canadians and their family members.   

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