Ontario Hepatitis Treatment

Costs

Pegylated interferon and ribavirin is an expensive therapy. A year’s cost will be about $19,000. Few patients are able to pay for this unaided. Therefore, for most patients some form of reimbursement will be required. This will be mainly through the Ministry of Health and Long Term Care or through private insurers. A few patients will be eligible for co-payment from the manufacturers.

Section 8

Ontario Drug Benefit
www.health.gov.on.ca/english/public/forms/form_menus/odb_fm.html
Ontario Drug Benefit Formulary (OBD) will reimburse most patients for hepatitis C treatment. Each patient’s application undergoes review by an expert (section 8 or Individual Clinical Review).

Ontario patients belonging to one of the following groups and who are insured by OHIP are eligible for coverage

• Trillium Drug Program recipients

• There is a deductible from the benefits for the Trillium program. This is on a sliding scale according to income, and is maximal at 4% of income.
• People 65 yrs of age and older
• Residents of long-term care facilities
• Residents of Homes for Special Care
• People receiving professional services under CCAC
• Social Assistance
  • Ontario Works (OW)
  • Ontario Disability Support Program (ODSP)

The address to send applications is:
Drug Programs Branch
5700 Yonge St, 3rd Floor
Toronto, Ontario
M2M 4K5
1-866-811-9893
Fax: 416-327-8123

Private Insurers

All private insurers will pay at least some of the costs of treatment. However, the extent of coverage varies from as little as 50% to 100%. Thus many patients will require Trillium Program assistance as well as private insurance.

PegAssist and Peg-CarePrograms

These are programs established by Roche and Schering to assist patients with obtaining reimbursement for hepatitis C treatment. Both programs will help with completing the necessary forms, and negotiating with the insurance companies. Peg-care can be reached at 1-800-603-2754
PegAssist can be reached at 1-877-PEGASYS

Federal and provincial Compensation Programs

Patients who became infected from transfusion of blood or blood products are entitled to compensation. There are two groups who qualify.

• Those who became infected between 1986 and 1990 are covered by the Federal Hepatitis C Compensation Program.
• Those who were infected prior to 1986 and after 1990 are eligible for a separate program administered by the Ministry of Health and Long Term Care. This is called the Ontario Hepatitis C Assistance Program.
• Some patients have also been compensated by a fund set up by the Red Cross, but that fund is now exhausted, and no further payments will be made.
• Finally, the Federal government has recently announced that the pre-’86 and post-’90 groups will also receive compensation. The details of this program have not yet been finalized. Further information is available at 1-866-225-0709 or (613) 957-2991.

National Legal Settlement/Funding Agreements for Hepatitis C

Ontario Hepatitis C Assitance Programs

Trillium Drug Program

www.health.gov.on.ca/english/public/pub/drugs/trillium.htmlThe Trillium Drug Program (TDP) is intended for Ontario residents who have a valid Ontario Health Card and who have high prescription drug costs in relation to their net household income.
The TDP provides coverage for prescription drug products listed on the Ontario Drug Benefit Formulary/Comparative Drug Index (Formulary) as follows :

• over 3,400 quality-assured prescription drug products;
• over 450 limited-use drug products;
• some nutritional and diabetic testing agents.

Drug products that are not listed on the Formulary are also considered for coverage for TDP recipients through the ministry's Individual Clinical Review (ICR/Section 8) mechanism on a case-by-case basis. (For more information : Ontario Drug Benefit : Section 8–Special coverage of a non-listed drug product Mechanism.)

Who?

You can register in the Trillium Drug Program if:

• you don’t have private insurance coverage or if your private insurance does not cover 100% of your prescription drug costs;
• you have a valid Ontario Health Card and are a resident of Ontario; and
• you are not eligible for drug coverage as another category of recipient under the Ontario Drug Benefit (ODB) Program (i.e., you are not a senior over 65 years of age, you are not a social assistance recipient, you are not receiving professional Home Care services, or if you are not a resident of a Long-Term Care Facility or Homes for Special Care); and
• you don't have private insurance coverage or if your private insurance does not cover 100% of your prescription drug costs.

Deductible

The program runs from August 1 to July 31 of the following year. Before you will receive coverage for eligible prescription drug products through the TDP, your household must pay for a set amount of your prescription drug purchases, otherwise known as the "deductible", each year starting August 1. The deductible is paid in four instalments over the program year and is calculated based on net household income and household size.
For example, a household with an annual deductible of $500 will pay for the first $125 of prescriptions purchased at the start of each quarter on August 1, November 1, February 1, and May 1. After the deductible is paid in each quarter, the household will be eligible to receive drug benefits for that quarter, and will be asked to pay up to $2 per prescription each time they purchase an eligible drug product. Any unpaid deductible in a quarter will be added to the next quarter's deductible.
New applicants to the TDP can choose the date within the program year on which they wish to be enrolled in the program. The deductible will be prorated, that is, the deductible will be based on the number of days left in the program year. Please note that proration of the deductible will apply only for the first year that a household/member is enrolled in the program.

Drug Costs

Only eligible drug costs count towards your Trillium Drug Program deductible or are covered as program benefits. To ensure coverage under the program, check with your pharmacist or health care provider to make sure your prescriptions fit into one of the following categories :

• are listed in the ODB Formulary/Comparative Drug Index; or
• are on the Facilitated Access List of HIV/AIDS drugs; or
• have been approved for coverage through the ministry’s Individual Clinical Review (ICR/Section 8) mechanism.

Where?

Trillium application kits are available at your local pharmacy, or by calling 1-800-575-5386. The application form and application guide are also available online :

• Application for Ontario Drug Benefits (A Guide to Your Application (Ontario Drug Benefit))

Trillium recipients contact

P.O. Box 337, Station D
Etobicoke, Ontario
M9A 4X3
Tel : 416-642-3038
Fax : 416-642-3034
Toll-Free : 1-800-575-5386
E-mail : trillium@resolve.com