Sometimes paying for needed medication
can mean financial hardship for persons with HIV/AIDS. This brochure is designed to ensure that you have the information you need to get the funding you require to pay for your important prescription
drugs. With HIV medications, especially antiretrovirals (including protease inhibitors), it is very important to take them regularly and continuously. Therefore, before starting any new drugs,
make sure you have appropriate payment mechanisms in place so that you do not have to interrupt your therapy unnecessarily.
In Ontario, coverage for drugs commonly prescribed in HIV/AIDS may often be
obtained through a variety of routes. These systems include the Sunnybrook HIV Project Centre, the Ontario Drug Benefit Program, public health departments, the Emergency Drug Release Program, and
private insurance plans. Please note that eligibility criteria may vary depending upon the individual patient, the program, and the prescribed drug.
1. Sunnybrook HIV Drug Project Centre Special Drugs Program
All patients living in Ontario who are registered with the HIV Drug Project Centre at Sunnybrook Health Sciences Centre are eligible to
receive certain medications (e.g., some antiretrovirals and aerosolized pentamidine) free of charge. Prescriptions for these agents must be filled at designated hospital pharmacies. To register,
your physician needs to fill out a form and send it to the Project Centre. Your name will then be kept as part of a confidential registry.
2. Ontario Drug Benefit Program (ODB)
There are currently 3 ways that Ontario residents may qualify for ODB assistance, and then become eligible to receive all ODB benefits, including HIV medications:
i.) Social Assistance (Welfare) or Family Benefits Assistance (FBA)
ODB is provided automatically if you are receiving either social assistance or family benefits
assistance. Social assistance benefits are for people who are temporarily unemployed. Family benefits assistance provides long-term benefits for people who cannot work for medical reasons and
have limited financial resources. However, it can take as long as 3-5 months to process an application for FBA, so usually people apply to Social Assistance in the meantime. To apply, call the
Welfare office in your area. Tell them you have no income, and are unable to work because of illness. They can start an application for you. A clinic social worker or a benefits counsellor
at the Toronto PWA Foundation can provide you with more information.
ii.) Home Care Programs.
ODB is provided automatically if you are receiving Home Care Service. Home care
programs provide professional services such as nursing and homemaking to make sure you can keep living independently at home. To qualify for Home Care you must be assessed, and deemed to require a
criteria service such as nursing. Your clinic nurse or your family physician can help arrange this.
iii.) Trillium Drug Program.
You can apply to the Trillium Drug Program if your total drug
costs in a year are excessive relative to a percentage (about 3-4%) of your net income. Applications must be made once each fiscal year (April 1 to March 31). Once you are enrolled in Trillium,
you will automatically be mailed a renewal application a few weeks before the next fiscal year commences.
Once you pay a deductible, your OHIP card is used by the pharmacist to access the coverage.
The exact amount of your deductible varies according to your income and whether you are single, in a spousal union, or in a family. You must save all receipts for prescription drugs and show your
income tax return or pay stubs for the previous year to establish your net income. You are entitled to use receipts for medications you have purchased (back to April 1 of the year in which you are
applying) towards your deductible. Application packages include an explanatory booklet and application form, and are available in most pharmacies, or you can also call 1-800-575-5386 or (416) 326-1558
You are advised to apply right away to Trillium if you think you will require assistance to pay for your HIV medications. It may take up to two months for your application to be
processed. It is not necessary to have spent money on medications up to your deductible before applying.
Even when you do qualify for ODB, the system can be complicated. There are four ways you can get your drug costs covered under the ODB. Please note that you will be required to pay a $2
co-payment for each prescription that is filled.
i.) Formulary list:
There is a list of drugs which are paid for if you have ODB coverage. You must show your proof of
enrollment/coverage to the pharmacist when ordering your medication. The list includes common drugs like cotrimoxazole (Septra/Bactrim), dapsone, ketoconazole (Nizoral), ciprofloxacin, etc.
ii.) Facilitated Access:
There is a special list of HIV/AIDS drugs which registered doctors may prescribe. Many pharmacists are unaware of this list so you may have
to insist, or go to a pharmacy which is familiar with dispensing these medications. Some common drugs on this list include fluconazole (Diflucan), acyclovir (Zovirax), and atovaquone (Mepron).
iii.) Limited Use:
This is a list of drugs which are only covered under certain circumstances. It requires some paperwork on the part of your physician. You must present
your pharmacist with a "Limited Use/Nutrition Products Form" signed by your doctor. The list includes some antiretrovirals (e.g., 3TC, d4T/stavudine, and certain protease inhibitors such as
saquinavir/Invirase, indinavir/Crixivan, and ritonavir/Norvir).
iv.)Section 8 Requests:
This is a procedure where a doctor applies for coverage for you for a particular drug not on any of these
lists. When requests are granted, coverage is usually given for a limited period of time, so your physician or nurse may have to reapply later on. This can be a cumbersome paper-heavy
process. Presently, Section 8 requests need to be made to get drugs such as oral ganciclovir (Cytovene) capsules, or sulfadiazine tablets.
Please note that ODB coverage is not
comprehensive. Most investigational and complementary therapies are not covered under ODB. If you are not in a study that pays for these medications, you will have to pay for them yourself
3. Public Health Department (for drugs to treat tuberculosis)
Drugs used to treat tuberculosis (i.e., isoniazid, rifampin, ethambutol, pyrazinamide,
pyridoxine) are provided free of charge through either the provincial or local departments of public health. You may need to pick up your medications at a designated hospital pharmacy.
4. Emergency Drug Release Program (EDRP)
To obtain medications that are currently not licensed in Canada, your physician needs to contact the Health Protection Branch in Ottawa and make a
specific request on your behalf. These drugs are often (but not always) provided free of charge, and a dispensing fee may be charged.
5. Private Insurance
If you have
private insurance that covers drug costs, you may need to check with them or ask your pharmacist to see whether they will cover all of your needed medications. Some plans may have annual expenditure
caps, charge an annual deductible, or require that you pay a percentage of all your prescription medication costs. For example, many plans only reimburse 80% of all drug costs. If you find that
paying the rest of your drug bill out of your own pocket to be difficult, you may also be eligible to apply for the Trillium Program.
6. Extraordinary Assistance
agencies and hospitals can sometimes help you pay for drugs on a temporary basis, subject to different qualification tests. This assistance varies depending upon the setting, but usually is a
"one-time" grant to help persons who are in immediate need until they can arrange for one of the programs already discussed. Please note that in most instances, you will have to be receiving medical or
support services at these hospitals or agencies to be assess for eligibility. You will have to approach them yourself to find out if they offer services to your community, and to see if they can be
helpful to you.
The following are the names and telephone numbers of some of these centres:
- The Wellesley Central Hospital David Dinn Fund (416) 926-7041
- Toronto P.W.A. Foundation (416) 506-1400
- Black Coalition for AIDS Prevention (BLACKCAP) (416) 926-0122
- Hospital for Sick Children Comprehensive Care Clinic (416) 813-6268
- Jewish Family & Child Services of Metropolitan Toronto (416) 630-7800
- The Teresa Group (Child and Family Aid) (416) 596-7703
- 2-Spirited People of the 1st Nations (416) 944-9300