Learn More >

Ministry Status: Routine Monitoring and Engagement

Ontario Public Drug Programs

Formulary

Conditions for Payment of a Dispensing Fee under the ODB Program

Ontario Regulation 201/96 under the Ontario Drug Benefit Act (the “ODBA Regulation”) establishes conditions for the payment of dispensing fees under the Ontario Drug Benefit (ODB) Program. In order to receive payment of a dispensing fee under the ODB Program, the dispenser must supply at one time the lesser of:

  1. the maximum quantity of the listed drug product that the dispenser is authorized to supply at one time; or
  2. the maximum quantity of a listed drug product for which the Executive Officer is required to pay under section 18 of the ODBA Regulation 1

The amount referred to above (in either item 1 or 2) is the “Maximum Quantity.”

1 As of August 1, 2018, for most ODB recipients, the maximum quantity for which the Executive Officer is required to pay would be a supply sufficient for a 100-day course of treatment; and in the case of medications to which the Trial Prescription Program applies, the maximum quantity for which the EO is required to pay is a quantity sufficient for 30 days.

Dispensers may dispense less than the Maximum Quantity and still be eligible to receive a dispensing fee in the following cases, subject to any additional requirements set out in the ODBA Regulation:

  1. The ODB recipient is a resident of a long-term care home (see “Exempted LTC Homes List”).
  2. The ODB recipient is a resident of any other residential facility funded by the Government of Ontario that is designated by the Executive Officer (e.g., Home for Special Care) and included in the list below (see “Other Homes List”).
  3. The listed drug product is a product or belongs to a class of drug product that is specified by the Executive Officer and included in the list below (see “Exempted Medication List No. 1”) and the dispenser has determined that the quantity supplied should be less than the Maximum Quantity because, in the dispenser’s professional opinion,
    1. The safety of the ODB recipient is a concern, or
    2. There is a risk of abuse or diversion if the drug product is supplied to the ODB recipient.
  4. The dispenser has determined that the quantity supplied should be less than the Maximum Quantity because,
    1. In the dispenser’s professional opinion, the ODB recipient is incapable of managing his or her medication as a result of physical, cognitive or sensory impairment; and
    2. The ODB recipient or the person presenting the prescription agrees that the quantity supplied should be less than the Maximum Quantity.

Back to top


Two Dispensing Fees / 28 Days

In most cases, the Executive Officer will only pay a dispenser a maximum of two (2) dispensing fees per 28 days for the supply of a listed drug product, even if the prescription directs more frequent dispensing. This rule is subject to the rule respecting Chronic-Use Medications.

Subject to any additional requirements in the ODBA Regulation, the two-dispensing-fees-per-month rule does not apply if:

  1. The ODB recipient is a resident of a long-term care home (see “Exempted LTC Homes List”).
  2. The ODB recipient is a resident of any other residential facility funded by the Government of Ontario that is designated by the Executive Officer (e.g., Home for Special Care) and included in the list below (see “Other Homes List”).
  3. The listed drug product is a product or belongs to a class of drug product that is specified by the Executive Officer and included in the list below (see “Exempted Medication List No. 1”) and the dispenser has determined that the quantity supplied should be less than the Maximum Quantity because, in the dispenser’s professional opinion,
    1. The safety of the ODB recipient is a concern, or
    2. There is a risk of abuse or diversion if the drug product is supplied to the ODB recipient.
  4. The listed drug product is supplied in the Maximum Quantity (see definition above) and is a product or belongs to a class of drug product that is specified by the Executive Officer and included in the list below (see “Exempted Medications List No. 2”).

Back to top


Dispensing Fees for Chronic-Use Medications

There is a limit on the number of dispensing fees that can be billed to the Executive Officer for certain chronic-use medications included in the list below (see “Chronic Medications List”).

Dispensers are entitled to receive a maximum of five (5) dispensing fees per 365-day period, commencing on the day the first claim for an identified chronic-use medication is submitted to the ministry.   Dispensers are encouraged to provide most ODB recipients with a 100 days’ supply of most chronic-use medications to ensure that they receive a dispensing fee for each dispensing event.

Subject to any requirements in the ODBA Regulation, this limit on the number of dispensing fees for chronic-use medications does not apply in the circumstances listed below. In these circumstances, the general rule of a maximum of two-dispensing-fees-per-28-days applies, unless the dispensing event is also exempt from that rule (see section above).

  1. The ODB recipient is a resident of a long-term care home (see “Exempted LTC Homes List”).
  2. The ODB recipient is a resident of any other residential facility funded by the Government of Ontario that is designated by the Executive Officer (e.g., Home for Special Care) and included in the list below (see “Other Homes List”).
  3. The listed drug product dispensed is an extemporaneous preparation.
  4. The ODB recipient is on a complex medication regime where patient safety is at risk and requires more frequent dispensing of the listed drug product to assist with the proper administration of the medication regime.
  5. The dispenser dispenses less than the Maximum Quantity because,
    1. In the dispenser’s professional opinion, the ODB recipient is incapable of managing his or her medication as a result of physical, cognitive or sensory impairment; and
    2. The ODB recipient or the person presenting the prescription agrees that the quantity supplied should be less than the Maximum Quantity.
  6. The ODB recipient is entitled to receive drug benefits under the Ontario Works Act, 1997 (“OW recipients”).
    Note: on August 1, 2018, this exception is revoked, meaning that drugs dispensed to OW recipients will be subject to the 5-dispensing-fees-per-year rule as of that date.

Exempted Other Homes List [Excel]

Exempted LTC Homes Lists [Excel]

Exempted Medications [PDF]

Image:Pdf icon.gif To view PDF format files, you need to have Adobe Acrobat® Reader installed on your computer.
You can download this free software from the Adobe Web site.


See also:

For More Information

Call ServiceOntario, Infoline at:
1-866-532-3161 (Toll-free)
In Toronto, (416) 314-5518
TTY 1-800-387-5559.
In Toronto, TTY (416)327-4282
Hours of operation: Monday to Friday, 8:30am - 5:00pm

 
  • Connect With Us
Facebook Twitter YouTube RSS