7B.8. Non-Formulary Drug Coverage

POLICY 

Authority OW Act: Sec. 2, 5 and 10 & OW Directives: Dir. 7.7

A participant may request special coverage for a prescribed drug that is not covered by the drug card as a Discretionary Benefit. This will only be considered in instances where an alternative drug is not available. The physician must clearly state why this particular medication is needed and also why a substitute drug is not acceptable. 

A participant may have this cost approved as a Discretionary Benefit temporarily while awaiting approval for the item to be covered by the Ministry of Health & Long Term Care’s Exceptional Access Program.
 

PROCEDURE

The participant should first be referred back to their Doctor to inquire if an alternative drug that is covered by the formulary can be prescribed. 

If there is no other drug within the current formulary that can be taken by the individual, the prescribing physician or dentist may request coverage under the Exceptional Access Program to have that drug covered for that specific person.

1. The physician should clearly state why this particular medication is needed and also why a substitute drug is not acceptable. Confirmation letter from the physician should be obtained whenever possible. This process takes approximately six weeks with no guarantee that the drug will be approved.

2. The physician will mail this information to:

Ministry of Health & Long Term Care
Individual Eligibility Review Branch
Exceptional Access Program
5700 Yonge Street, 3rd Floor
Toronto, Ontario  M2M 4K5 

Tel:  (416) 327-8109
Fax: (416) 327-7526 

3. If physician does not have the special authorization form (Individual Clinical Review), they may be obtained by telephoning Kingston at 1-888-310-9008 

4. Confirmation letter from physician is required to verify that the special authorization for this drug has been applied for and why this medication is required. We will assist until a decision is made - approximately six weeks.

5. If the individual coverage for the drug is granted, a duplicate copy of the approval will be provided to the physician with instruction that it be forwarded to the pharmacy. 

Note:  Over the counter medication is not covered by the drug card nor will it be covered by Discretionary Benefits. 
 

TRILLIUM DRUG PROGRAM                  

Since April 1, 1996, assistance with prescription drug costs have no longer been provided under Discretionary Benefits. However, participants may be eligible for medical coverage through the Trillium Drug Program (TDP). 

For more information, Participants can call the TDP hotline at 1(800)575-5386. Participants can also pick up an application package at their local pharmacy.