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Ontario Drug Benefit (ODB) & OHIP+

Who is Eligible

Ontario Drug Benefit: This program covers the costs of prescription drugs used by Ontario residents with a valid Ontario Health card who are 65 years or older and who are not hospitalized (outpatients). People may qualify before age 65 if they meet one of these criteria:

  • Living in a long-term care home or a home for special care
  • Enrolled in one of these programs:

For more information: Get coverage for prescription drugs

OHIP+: This program covers prescription drugs used by Ontario residents with a valid Ontario Health card who are 24 years of age or under and are not covered by a private insurance plan. For more information: OHIP+

For more information: OHIP+

Drugs listed as “General Benefit”

For people receiving ODB or OHIP+ coverage, the following GN medications are listed in the ODB Formulary and covered under general benefit (patients do not need to meet any specific clinical criteria to be funded):

  • Azathioprine
  • Cyclosporine
  • Cyclophosphamide (oral)
  • Mycophenolate Mofetil (CellCept®)
  • Mycophenolate Sodium (Myfortic®)
  • Prednisone

Drugs listed as “Limited Use”

ODB funds some drugs where patients must meet specific clinical criteria for drug coverage and are listed as “Limited Use” benefits in the formulary.

Rituximab for the indication of Granulomatosis with Polyangiitis (GPA)/ Microscopic Polyangiitis (MPA)

  • Riximyo
  • Ruxience
  • Truxima

These drugs are reimbursed for induction or maintenance of remission in patients that meet specified criteria. The limited use code is required to be written on the prescription. For the most up-to-date information on eligibility criteria, limited use codes and which rituximab products are funded, see the eODB formulary.

Exceptional Access Program

Prescribers may request coverage under Exceptional Access Program (EAP) for medications not covered under The ODB formulary.

To apply, prescribers submit a request using the new digital web portal – “SADIE”. Alternatively, prescribers can fax a completed EAP form to 416-327-7526. Response time is variable.

To find up-to-date wait times, visit Exceptional Access Program and select “Turnaround Times” from the list.

To receive coverage, patients must quality for ODB benefits. Prescribers may wish to check if their patients need to register in the Trillium Drug Program prior to applying.

Patients who choose to purchase unlisted drugs in advance of an EAP decision are responsible for out-of-pocket costs.

For more information: Exceptional Access Program

Medications considered under EAP

Compassionate Review Policy

The Exceptional Access Program has a Compassionate Review Policy (CRP) that will consider medication requests for patients with rare clinical circumstances for immediately life, limb, or organ-threatening conditions. For GN medications that are not covered by the ODB formulary or EAP, prescribers may wish to submit a request to the CRP.

To apply, prescribers can fax a completed CRP Initial Request Form to 416-327-0981. Each request is assessed on a case-by-case basis.

To receive coverage, patients must quality for ODB benefits. Prescribers may wish to check if their patients need to register in the Trillium Drug Program prior to applying.

Patients who choose to purchase unlisted drugs in advance of a CRP decision are responsible for out-of-pocket costs

For more information: 

Compassionate Review Policy

CRP Initial Request Form

Medications considered under Compassionate Review Policy

  • Tacrolimus
    Indication: Prescribers may apply to CRP for tacrolimus products for GN indications (e.g., the patient is intolerant to cyclosporine)

 

Disclaimer: The information contained herein (“Information”) is intended for informational purposes only, and no warranty as to its accuracy is provided or implied. The Information was collected from third party sources and is subject to change without notice. Ontario Health (Ontario Renal Network) makes no warranty that the Information is current. The Information is intended for use by healthcare professionals to advise patients of drug funding options that may be available to them. Do not act or rely upon the Information without exercising your independent judgment or seeking the advice of a qualified professional. Anyone using the Information does so at his or her own risk. The drug funding options described on this website are managed and funded by third parties, not by Ontario Health (Ontario Renal Network). Please direct any inquiries to the applicable agency/entity who manages the drug funding option.