In August 2016, Ontario announced changes to its drug benefit program. The province raised the income threshold for access to the deductible-free plan, but it paused a proposal to increase the deductible and co-payments for seniors who don’t qualify for the low-income plan.
The Ontario Drug Benefit
The Ontario Drug Benefit is a program to help seniors over the age of 65 years pay for prescription drugs. If you live in a long-term care home, you can qualify for this program before your 65th birthday. Additionally, participants in Home Care, Ontario Works, the Ontario Disability Support Program or the Trillium Drug Program can also take advantage of ODB, regardless of their age.
Changes to the ODB in 2016
In 2015, single seniors with incomes less than $16,018 and senior couples with incomes less than $24,175 qualified for special benefits under the ODB program. However, as of August 2016, the government increased these income thresholds to $19,300 for single seniors and to $32,300 for senior couples.
To explain, imagine you are a single senior who earned $19,000 in 2015 and 2016. In 2015, your income was over the threshold, and as a result, you qualified for ODB benefits, but you did not qualify for the special benefits for low-income seniors. However, in 2016, you qualify for special benefits, because the income threshold is higher.
Seniors With Incomes Over the Threshold
If you are a senior and your income is over the threshold, you must pay a $100 deductible per person per year. This means that the ODB doesn’t kick in until after you have spent $100 on prescription drugs. After you pay the deductible, you must pay a $6.11 co-pay for each prescription.
If you are married, you and your spouse may both receive OBD benefits, as long as you are both over the age of 65, but you must pay the deductible separately. To illustrate, imagine you have bought $100 worth of prescription drugs, and you have started to pay the $6.11 co-pay for your new prescriptions. At that point, your spouse receives her first prescription of the year. Although you have satisfied your deductible, she has not. As a result, she must pay the full cost of her prescription medications until she meets her $100 deductible. Then, you are only responsible for the co-pay until the new year starts and you both have to satisfy the deductible again.
Applying for the ODB
You don’t need to apply for the ODB. The Ontario Ministry of Health and Long-Term Care will send you a letter approximately three months before your 65th birthday, inviting you to take advantage of the program. To prepare, you may want to talk with your doctor to ensure that the medications prescribed to you are covered. The program covers the costs of 4,300 prescription drugs as well as allergy shots, Epipens, diabetes testing products and a range of other costs. Your benefits start on the first day of the month following your 65th birthday. On that day, you can go to the pharmacy and start using the benefits right away.
However, if your income is under the threshold and you want to take advantages of the deductible-free plan, you must submit a Co-Payment Application for Seniors. You can obtain an application from your pharmacy or contact the Ministry of Health and Long-Term Care for one. As indicated above, you can qualify for the ODB if you participate in certain social assistance programs or if you live in a long-term care home or a home for special care. In these cases, you do not have to apply for the ODB, and you automatically qualify for the deductible-free program.
The ODB runs from July to June of every year. If you become eligible in the middle of the year, your deductible is pro-rated. For example, if your birthday is in October, you become eligible for the ODB on November 1. That means you are only using the program for nine months or three-quarters of the year; as a result, your deductible is only $75, which is three-quarters of the full deductible amount.
In addition to changing the income limits, the government of Ontario also considered changing the deductible and co-pays for seniors with incomes over the threshold. The province considered increasing the annual deductible from $100 to $170 and boosting the co-pay from $6.11 to $7.11. However, after talking with citizens, the government ultimately decided to pause these proposed changes to the deductible and co-pays.