October 7, 2012

How to get 100% prescription drug coverage from the Ontario Government (Dispelling Myths about the Trillium Drug Program)

October 7, 2012

The Ontario government has a drug plan called the Ontario Trillium Drug Program (“Trillium”). This is available to Ontarians who either:

  • do not have drug coverage; or,
  • who have reached the maximum on their drug coverage; or,
  • their drug deductibles are very large compared to their household income.

Trillium steps in and help Ontarians very much like the Ontario Drug Benefit (ODB). TheODB is a drug plan for Ontarians over 65, on ODSP or on OW (welfare).Trillium is an extension of the ODB, such as a means-tested benefit. The philosophy of this plan believes that the government should help foot the cost of drug bills for Ontarians who are faced with an expenditure which exceeds 4% of their household income.Once someone has paid 4% of their income out of pocket for their drugs (paid quarterly), they are eligible for Trillium to step in and pay the rest.Exceptional Access ProgramTrillium goes by the ODB formulary, a restrictive formulary (drug list) which does not cover everything. However, there is an Exceptional Access Program (EAP) which is an appeals process. This allows people to apply for rare or experimental drugs which are not on the ODB.If someone is first declined coverage for a particular drug by Trillium, they can apply to theEAP and apply on the basis that there is nothing on the ODB which can help. Their doctor would be part of that process.There is a deductible. People are expected to pay between 3% and 4% of their family income out of their own pockets before Trillium steps in (or becomes the “first payer”).ExampleIf a person needs $10,000 worth of drugs annually and is making $50,000 per year, his deductible is 4% of his household income, which equals $2,000.Trillium pays the difference of $8,000.Trillium works quarterly. If the cost of the drug is $10,000 per year, itʼs $2,500 perquarter. If the deductible is $2,000 per year, itʼs really $500 per quarter. Once he paysthe $500 in the first quarter, Trillium pays 100% of the cost of the drugs in that quarter. In the second quarter of the year, he again pays $500 out of his pocket, and then Trillium pays for the rest.If this person has an employer drug benefit plan, but the plan has a maximum of$10,000 per year, then he can certainly take advantage of Trillium regardless of the co-insurance level of his plan.Trillium becomes the first payer once the deductible has been satisfied - not just when the max has been reached.Dispelling MythsTrillium is often misunderstood by benefit consultants, employers and employees. If you, for whatever reason, have to put your hand in your pocket and pay that $500 perquarter, then Trillium will step in on a quarterly basis and become the first payer.On the surface, the law for this seems to say that as long as you have a drug plan,Trillium is the second payer. In reality, this is not how it works. The law says that if theamount you pay out of pocket is more than the Trillium deducible, then Trillium becomes the first payer.“But my employer has a drug plan – why would I need to use this?”First of all, if you reach your employer’s drug maximum, it steps in.Second, supposing your employer plan pays 80% of drug costs, and you must pay 20% out of your pocket. There is a way to have the government cover your 20% once you’ve reached the deductible.Going back to our example, a person is spending $2,000 per month on drugs and has an employer drug plan which covers 80% of those costs.On January 1st, he goes to the pharmacy and pays $400 for the 20% co-pay. The plan pays $1,600. He has now paid $400 towards the deductible.In month 2, he does the exact same thing. He has now paid $800 towards the deductible. He has satisfied the deductible for that quarter (which was $500 or 4% of family income). If he is registered and approved under Trillium, in month 3, Trillium becomes the first payer. Now, he can go to the pharmacy, can ask for that drug and not have to pay a penny out of his pocket.Note: Trillium does not pro-rate deductibles for a month. It doesnʼt work retroactively.Application form for the Trillium Drug Program:http://goo.gl/7UW3TA guide to understanding the Ontario Trillium Drug Program:http://goo.gl/MM6j0

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