Hepatitis C Treatment Coverage in Ontario (adapted from the CATIE website: www.hepcinfo.ca)
Prescription Drug Programs in Ontario
Individuals who receive social assistance, either through Ontario Works (OW) or the Ontario Disability Support Program (ODSP), may be eligible for prescription drug coverage through the ODB. The ODB and the Trillium Drug Program (TDP) are the two main programs that assist Ontario residents with covering the costs of expensive prescription drugs and may be able to help cover the high cost of hepatitis C treatment medications.
The TDP is available to all Ontarians who have high drug costs and who do not qualify for drug coverage through a different program. An annual deductible and co-payments (based on household income) apply to all recipients of the TDP, which is paid in four installments throughout the year.
In Ontario, peg-interferon and ribavirin are among the drugs that are eligible for coverage under the Exceptional Access Program (EAP). These hepatitis C medications must be approved for coverage by the EAP before they will be paid for by one of the publicly funded drug programs. People can ask their hepatitis C specialist to submit a request form to the EAP for coverage of their hepatitis C medications. The request form will be reviewed against the clinical criteria for coverage, set out by the Committee to Evaluate Drugs (CED).
Some of the factors that are considered when approving funding for hepatitis C medications include: a positive HCV RNA test, HCV genotype, elevated ALT levels or level of fibrosis, absence of cirrhosis, child-Pugh score, level of inflammation and whether or not an individual is treatment naïve and living with chronic hepatitis C. The requesting physician will receive a letter from the EAP telling them whether or not coverage will be granted or if more information is required. If the request is approved, people will have their hepatitis C medications covered for a designated time period. A request to extend the period of coverage is usually necessary in order for people to have their medications covered for the duration of their treatment.
Registered First Nations and recognized Inuit people may be able to access coverage for their hepatitis C medications through the Non-Insured Health Benefits (NIHB) program.
Private health insurance
Some health insurance policies offered through private insurance companies include (partial) coverage for prescription drugs. These programs often have their own deductible, or co-pay fee, and may have yearly maximums for prescription drugs. Often the patient needs to apply to the Trillium Drug Program to cover the remainder of the cost.