What is the Ontario Drug Benefit (ODB) Program?
The Ontario Drug Benefit for seniors is the province’s version of Pharmacare. It’s an insurance program that helps with the cost of prescription medications. There isn’t a federal Pharmacare program (although a Canada-wide solution is a possibility.)
Eligibility for the ODB
To be eligible for ODB program in Ontario you must:
- Be a resident of Ontario
- Be aged 65 or over
- Have a valid OHIP Health Card
As well, you must not already have a private health insurance plan.
You’ll be automatically enrolled in the program on your 65th birthday. The Ontario government will mail you a letter a few months before with details about the ODB program.
Some younger Ontarians may qualify if:
- You live in a care home
- You’re younger than 25 and not covered by private insurance
- You get professional home care services or benefits from Ontario Works or the Ontario Disability Support Program
What’s Covered by the Ontario Drug Benefit Program?
There are about 5,000 prescription drugs covered by the ODB program. You can search their formulary to see if your prescriptions will be covered. There are also some non-drug products that are covered:
- Epinephrine injectables and allergy shots
- Diabetes test strips and some diabetes related products
- Some prescribed nutrition products
Regardless of the drug:
- Both generic and brand name drugs may be covered
- They must be prescribed by a licensed healthcare professional, such as a doctor, dentist, pharmacist, midwife, optometrist or nurse practitioner
- The prescription must be filled at a pharmacy in Ontario
- The coverage may not be 100%
What’s Not Covered by ODB?
Here is a selection of items that not covered by the ODB. Essentially, it’s anything that is not listed in the formulary, or is filled outside of the province.
- Diabetic aids like compression socks or glucometers
- Nutritional products for meal replacement or weight loss
- Wound care like bandages and non-prescription ointments
- Over the counter cough, cold and flu medications
- Medicated soaps and shampoos
- Convalescent aids such as a cane, shower support, or feeding cup
What Does the Ontario Drug Benefit Cost?
The program isn’t free. The amount you have to page is based on your annual income. For single seniors who earn more than $22,000 or couples who earn more than $37,100 there is a $100 deductible that is paid down as you get your prescriptions filled. After the deductible there is a co-payment of up to $6.11. If your income is below these levels, the fees are less.
Is it Best to Have Private Health Insurance or the ODB?
For the most part, the Ontario Drug Benefit program is only covers the cost of prescription medications. The best decision for you will depend on your healthcare situation. There are a number of things to consider:
- How much are the medications that you and your spouse currently take?
- Do you currently have dental, physio, vision or other healthcare needs?
- Do you or your spouse have pre-existing conditions?
- How old is your spouse when you turn 65?
- Do you have employer benefits that expire when you are age 65? What will happen to your spouse’s coverage?
Maybe your spouse is a better fit for private insurance. Perhaps your specific drugs aren’t covered by the Ontario formulary. Or maybe you’re both in great health and it’s not a concern.
It’s comforting to know that most seniors in Ontario will be eligible for drug benefits, for little cost. However, prescription medications may be only a portion your future health care expenses, which makes a private plan look more attractive. However, the details and fine print of an insurance plan can be complex and requires some expertise to understand. It’s also a recommended to not wait until you’re 65 to sort it all out. Planning your health insurance before you retire can be an important part of your overall financial planning. Take a look at our Blue Cross health insurance options for Ontarians.
Need help with this important decision? Contact one of our health insurance advisors.