Ontario Drug Benefit Program (ODB)

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like_to_retire
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Ontario Drug Benefit Program (ODB)

Post by like_to_retire »

I am confused somewhat about the logistics of this program and how it integrates with a private existing drug health care plan.

I have a Health Care Plan through my last employer that continued into my retirement that pays 90% of my drug costs. It's quite convenient since I'm able to take drug prescriptions to the pharmacy and they link directly to the insurance company at point of sale and the amount I pay at the cash is about 10% of the total cost. I don't have to send in receipts or interact with the insurance company. It's all handled at the pharmacy. Works great, and the cost per month from my pension is very reasonable.

When I turned 65 this year I received a letter from the Ontario Ministry of Health telling me I now qualified for the Ontario Drug Benefit Program (ODB) and I didn't have to do anything but show my health card at the pharmacy and tell the clerk I qualified for the ODB now, and the ODB would pay for the drugs, but I would still have to pay $6.11 for each prescription along with a $100 deductible per year (although the year I turn 65 has a sliding deductible scale). Seemed simple enough.

I took my first prescription to the pharmacy (Shoppers Drug Mart) after turning 65 and they seemed clueless about the whole Ontario Drug Benefit Program thing. They said their system showed my drugs were covered by my private insurance and that was that. They put the prescription through and I paid my teeny 10% fee. I was confused, but I don't have a lot of drugs to buy so I let it go.

Now, six months later, I get a letter from my private insurance company about something totally unrelated with regards to a small fee increase every month to cover inflation, but at the bottom of that letter it has a section that says "For those turning 65". It says, once you are eligible in your province for a government drug plan, you must first submit all prescriptions through that plan first, and then submit the remainder to the private drug plan second. Claims not submitted to the government plan may be declined.

Now to my question. For those of you taking advantage of the ODB and also have a private drug plan, what are the logistics? Does the pharmacy send the prescription through their computer first and then the ODB applies the deductible and returns them a cost to the customer, then the pharmacy transmit that value to the private plan? I am still scratching my head why Shoppers Drug Mart was so clueless about the ODB.

What are your experiences with this rather confusing situation?

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adrian2
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Re: Ontario Drug Benefit Program (ODB)

Post by adrian2 »

I'm not yet 65, but my health plan from work seems similar to yours: when over 65, one has to submit to ODB first, then the plan will cover the rest. So basically the plan's covering what ODB does not.

One has to show the OHIP card at the pharmacy once, then their system verifies the details electronically with OHIP (and indirectly with CRA), then you're set.

Remember the $100 deductible runs every year from August 1 to July 31.

My mother has just ODB, no other plan, so she pays about $2 deductible per prescription at Costco after the $100 per year is met.
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Re: Ontario Drug Benefit Program (ODB)

Post by ghariton »

I get ODB and I'm included in a private plan that is part of my wife's post-retirement benefits from the federal government (run by Sun Life). I also use Shopper's Drug Mart.

My recollection is that when I turned 65, five years ago, I gave the pharmacy both my OHIP card and the Sun Life card, which they duly noted. As a result, almost all of my prescriptions were reduced to some $6 or $4. A couple of years ago, Shoppers started absorbing this residual, so now, for most medications, I pay zero. No forms, no mailings, no nothing. I assume that there is account information accessible on line, but since it is in my wife's name, I can't access it (and she can't be bothered).

There are exceptions: (1) I still have to "work off" the deductible each year (2) some recent drugs are not covered by ODB and so I have to pay for them -- as much as $45 in one recent case.

Works very smoothly for me.

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Re: Ontario Drug Benefit Program (ODB)

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ghariton wrote:My recollection is that when I turned 65, five years ago, I gave the pharmacy both my OHIP card and the Sun Life card, which they duly noted. As a result, almost all of my prescriptions were reduced to some $6 or $4. A couple of years ago, Shoppers started absorbing this residual, so now, for most medications, I pay zero. No forms, no mailings, no nothing.
Huh, interesting. I certainly gave them my Sun-Life card years ago and that's worked out great. It's just when I tried to give them my Health Card after I turned 65 it seems they were clueless about the situation. I guess the next time I have a prescription I'll have to push a little harder.

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Re: Ontario Drug Benefit Program (ODB)

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I can't believe a place like Shoppers Drug Mart doesn't know how to handle seniors' prescription payments. They must submit first to ODB, then to the private plan, and you pay whatever is left. ODB has a $100 annual deductible starting in August, so the pharmacy will submit a higher amount to the private plan until that deductible is used up. My private plan also has a $100 deductible in January, so I pay a higher amount then. Most private plans demand that you submit to ODB first once you turn 65. With most plans being electronic now, it's easy and fast; no need for claim forms.
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Re: Ontario Drug Benefit Program (ODB)

Post by CROCKD »

I have been covered by ODB for some years. I do not have any private coverage. I get all my prescriptions from Shoppers Drugmart. As mentioned by other posters the pharmacy submits all the paperwork. Once the annual deductible is paid starting August 1st I have been paying $4.11.
However I am awaiting for the NEW costs starting August 1, 2016. This is because in the last Ontario budget the deductible was increased to $170 from $100 and I expect maybe the pharmacy might increase the co payment from $4.11. Officially the copayment was $6.11(now7.11( but Shoppers, Pharma Plus and maybe some others reduced it by $2.
Last edited by CROCKD on 13 Aug 2016 13:06, edited 1 time in total.
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Re: Ontario Drug Benefit Program (ODB)

Post by like_to_retire »

CROCKD wrote:As mentioned by other posters the pharmacy submits all the paperwork. Once the annual deductible is paid starting August 1st I have been paying $4.11.
So if you give the pharmacy a prescription at the start of the year for $30, then does the pharmacy charge you $30 for the pills and the deductible is now paid down to $70? Do you receive any indication of this on the receipt?

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Re: Ontario Drug Benefit Program (ODB)

Post by stardancer »

like_to_retire wrote:
CROCKD wrote:As mentioned by other posters the pharmacy submits all the paperwork. Once the annual deductible is paid starting August 1st I have been paying $4.11.
So if you give the pharmacy a prescription at the start of the year for $30, then does the pharmacy charge you $30 for the pills and the deductible is now paid down to $70? Do you receive any indication of this on the receipt?

ltr
I suppose it would depend on the pharmacy; the one I use (small town) doesn't keep track of my deductibles, but the pharmacist always warns me when they start. I will have to pay the deductibles, whether the receipt keeps track or not.
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Re: Ontario Drug Benefit Program (ODB)

Post by auntyvirus »

Also everything you pay for out of pocket like prescription deductibles is eligible as a medical deduction on your income taxes.
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Re: Ontario Drug Benefit Program (ODB)

Post by adrian2 »

CROCKD wrote:However I am awaiting for the NEW costs starting August 1, 2016. This is because in the last Ontario budget the deductible was increased to $170 from $100
There was a huge outcry about this budget proposal and it was rescinded.
It's still $100.
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Re: Ontario Drug Benefit Program (ODB)

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ghariton wrote:My recollection is that when I turned 65, five years ago, I gave the pharmacy both my OHIP card and the Sun Life card, which they duly noted. As a result, almost all of my prescriptions were reduced to some $6 or $4. A couple of years ago, Shoppers started absorbing this residual, so now, for most medications, I pay zero. No forms, no mailings, no nothing.
George, are you saying that the $100 deductible is also covered by Sun Life, and that from the ODB start date of August 1st you still pay only the $6.11?

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ghariton
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Re: Ontario Drug Benefit Program (ODB)

Post by ghariton »

No, alas, the deductible comes out of my pocket. Unfortunately, I can't remember how much it is.

I no longer pay the $6.11. The price for most prescriptions is now zero, with the difference picked up by Shoppers. I recall that they used to pay $2, reducing the $6.11 to $4.11, but these days even the $4.11 has been eliminated. Of course, I don't know whether this holds at all Shoppers. The competition in our neck of the woods is pretty fierce, with two new pharmacies opened in the last two years. (We have lots and lots of seniors around here.)

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Re: Ontario Drug Benefit Program (ODB)

Post by OhGreatGuru »

a) There is no good reason why the person(s) at Shoppers would not know about the Ontario Drug Benefit (ODB) Plan.
b) One confusing part about the ODB is that the annual deductible starts over again about the middle of the year, rather than calendar year. Whereas your private insurer may have a deductible that goes on calendar year.
c) As noted, Shopper's has an additional discount for seniors of up to $2/prescription, so often you pay nothing.
d) One criticism I have about Shoppers is that their receipts do not clearly show how much is paid by ODB, and how much by your private insurer (if they are submitted direct.) I have to go on-line with my supplementary health plan to clarify this. My receipts from Guardian Drugs are much clearer.
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Re: Ontario Drug Benefit Program (ODB)

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OhGreatGuru wrote:a) There is no good reason why the person(s) at Shoppers would not know about the Ontario Drug Benefit (ODB) Plan.
You're right OhGreatGuru, there's no good reason why Shoppers didn't know about the ODB when I submitted my first prescription after turning 65.

Yesterday, I took my second prescription to Shoppers Drugs (after the first was a failure, post 65 years old). I asked to see the pharmacist so I could get an answer to the problem I had with the first prescription.

She was definitely confused why my first prescription (after turning 65) wasn't put through the ODB, although she initially said maybe because it was in the month that I turned 65, but no, we established that it was past that date. Then she thought maybe the clerk didn't properly set up the account for the initial prescription (an error). Unless the account is properly setup, then the prescription will be rejected by ODB. I suspect this was the problem, and was the fault of an unaware clerk, because the pharmacist set the account up and submitted it without a problem, and it correctly went first to ODB and accepted, and the remainder went to Sun Life - no problems.

I had also been scratching my head about the ODB $100 deductible. They don't appear to strip the entire prescription cost out of the deductible. It appears they meter it out a bit through the year until the $100 is reached. I don't know the formula, but for my first prescription yesterday (which was under $100), they still paid a portion of it. Then the remainder was automatically sent to Sun Life and they paid their percentage as usual. The cumulative amount I burnt off the ODB deductible was clearly shown on my receipt. So once the ODB deductible is paid, I guess Sun Life will be charged about $4-$6 per prescription and no doubt they will likely waive that small amount.

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Re: Ontario Drug Benefit Program (ODB)

Post by CROCKD »

Well my Shoppers, and I have been in the plan several years as I am over 70, charges me the full amount after August 1 until the $100 deductible is reached.This usually takes 2 or 3 prescriptions and then by usually October, I am paying $4.11.

I am in central GTA. Seems like there are different approaches but I don't know why.
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Re: Ontario Drug Benefit Program (ODB)

Post by OhGreatGuru »

Glad you got it straightened out. An error on the clerk's part would have been my best guess, but I did not want to cast aspersions.
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Re: Ontario Drug Benefit Program (ODB)

Post by j831robert »

As with CROCK-D ABOVE. and happy with it s !
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Re: Ontario Drug Benefit Program (ODB)

Post by RafaelFrost05 »

who knows how to get benefits for rehabilitation in the private rehabilitation center of Ontario?https://canadiancentreforaddictions.org ... rug-rehab/ Maybe there are some support programs?
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Re: Ontario Drug Benefit Program (ODB)

Post by OhGreatGuru »

I don't have the answer to your question, but I would suggest you post it as a new thread, as it has nothing to do with ODB.
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Re: Ontario Drug Benefit Program (ODB)

Post by RafaelFrost05 »

OhGreatGuru wrote: 04 Sep 2017 15:15 I don't have the answer to your question, but I would suggest you post it as a new thread, as it has nothing to do with ODB.
Thank you! I will do so!
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