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August 13, 2013

Pharmacare: What is Publicly Funded in Ontario

written by Josie Newman

Here in Ontario, we excel among other provinces in our coverage of seniors' drug costs. We cover those on social assistance, ODSP, and in long-term care but there is plenty of room for improvement in our coverage of the working poor and others who have marginal incomes. 

PharmaCare for Seniors

Through the Ontario Drug Benefit Plan, our province's biggest publicly funded pharmacare program, full pharmacare coverage is provided to residents 65 and older regardless of income. Seniors in the lowest income bracket pay no deductibles for their prescriptions, while the remainder of seniors pay an annual $100 deductible. 

Seniors who earn less than $16,018 per year if they are single or less than $24,175 per couple pay no deductibles but do pay $2 each time they get a prescription filled. Those single seniors who earn more than $16,018 pay an annual deductible of $100 and up to $6.11 each time they fill a prescription while those senior couples who earn more than $24,175 annually pay a $100 deductible between them and up to $6.11 to fill each prescription.   

ODB also provides full coverage, with no deductible and up to $2 per prescription, to Ontarians in long-term care facilities, those utilizing home care or those receiving Ontario Works and ODSP. 

ODB pays only for the 3,800 drugs listed in Ontario's Drug Formulary, as well as for some limited use drugs, injections for severe allergy symptoms, diabetic testing strips, and some nutrition products if they are the patient's sole source of nutrition. The Exceptional Access Program is for those 850 prescription drugs not on the ODB list, but which are often needed because one of them could be all that is effective for certain people's illnesses. Applicants must first qualify for ODB and then have their physician apply for Exceptional Access on their behalf.   

Ontario’s Trillium Drug Program
The most relevant and far-reaching of all Ontario's pharmacare programs is the Trillium Drug Program. It is for Ontarians of all ages and all income brackets who have high prescription costs relative to their household income. Drug costs are subsidized so they do not exceed 2% of a household's net income on the lowest end of the income scale up to 4% at the highest end of the scale. A person is eligible provided they don't have private insurance or their insurance doesn't cover 100% of their drug costs, they are not on Ontario Works or ODSP, they don't live in long-term care or get home care.

Deductibles are calculated based on the previous year's net income and are paid quarterly. For example, if you earn between $28,501 and $29,000 and are single, you pay $894 annually for deductibles. The deductibles are divided in four and once you have paid the equivalent of the quarterly deductible through your prescription purchases, Trillium pays for the rest of your drugs for that three month period. In addition, a $2 fee is charged per prescription.

Although the program is beneficial in terms of its subsidies, those who earn less than enough to pay for basic necessities such as rent, public transportation, food, personal toiletries, phone and internet, furniture, clothing, and the dentist are still faced with the dilemma of either skipping some of those essentials or forgoing their prescriptions.

The single person earning $28,501 for example, is considered one of the working poor anywhere in Canada. In Toronto, a one-bedroom apartment costs between $1,200 and $1,600 per month, not including utilities like hydro.

Other monthly costs include:
TTC Metropass at $128.50
healthy food -- $300 to $400
internet connection --  $45 to $50
telephone land-line -- approximately $90 per month
tv cable -- $50
clothing and personal toiletries -- a minimum of $100

These basic costs alone are almost $2,200. If a person earning this much wants to further their education, go to the dentist, purchase prescription drugs, buy insurance, buy a car, own a pet, buy furniture, dishes or other personal items, buy gifts for others, join a club or other recreational pursuits, take a vacation, or save for the future they must make some hard choices because their monthly income would be just under $2,300 per month. Even with the support of the Trillium Drug Program, s/he must still pay $212.25 every three months which amounts to $70.75 monthly before receiving free prescriptions. 

On the other end of the scale, a single-person household which nets $80,000 pays $3,189 in annual deductibles, which translates to $797.25 quarterly or approximately $199 a month, a drop in the bucket for a high wage-earner. If the wealthier person is an entrepreneur with no health insurance plan, is employed by a company but doesn't want to pay deductibles for the company's insurance plan, or has the plan but wants to top it up because of their high prescription needs, s/he can be well taken care of through the Trillium plan.  

Although the Trillium Drug Program is a step in the right direction toward public pharmacare, it is still inadequate because the working poor are unable to comfortably cover their drug costs. Considering Ontario has the largest population of any province, they make up a large portion of the 23% of Canadians (see first pharmacareblog) unable to fill prescriptions because of financial constraints.  

Ontario's Specialized Drug Programs

Other drug programs which are invaluable to Ontarians suffering from the diseases they treat include TheNew Drug Funding Program (NDFP) which subsidizes some approved intravenous cancer drugs administered in hospitals. Cancer Care Ontario oversees the program but an applicant's doctor will determine whether they are eligible based on the type of cancer they have and the drug they need. NDFP pays for 100% of approved cancer drugs as long as the patient receives them at a regional cancer centre, Princess Margaret Hospital or a community hospital.

The SpecialDrugs Program subsidizes the full costs of outpatient drugs for serious conditions such as cystic fibrosis, thalassaemia, children with growth failure, and Gaucher's disease. Zidovudine and pentamidine for HIV infection, erythropoietin for anemia due to end stage kidney disease, cyclosporine after a solid organ or bone marrow transplant, and clozapine for schizophrenia are all fully subsidized through this program as long as they are obtained from a designated treatment centre with a doctor's referral.       

TheInherited Metabolic Diseases Program (IMD) covers the full costs of some outpatient drugs, supplements, and specialty foods used to treat people with metabolic disorders included in the program and who receive their drugs at a designated treatment centre. Patients with amino acid, carbohydrate, and cholesterol biosynthesis disorders, those with fatty oxidation defects, gluconeogenesis, mitochondrial, organic acid, urea cycle, and vitamin/cofactor disorders are all candidates for the program. Some drugs and supplements included are modified L-Amino acid mixtures, special low protein foods, infant feeds, and enteral feeds.

The RespiratorySyncytial Virus Prophylaxis for High-Risk Infants Program which fully subsidizes the drug palivizumab for infants who suffer from this serious lower respiratory tract infection, and the VisudyneProgram named for the drug which is used in some situations to slow age-related macular degeneration of the eyes are two other public pharmacare programs Ontario has to offer its residents.   

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