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Ministry Status: Routine Monitoring and Engagement

Ontario Public Drug Programs

Formulary

Conditions for Payment of a Dispensing Fee under the ODB Program

Effective August 1, 2008, changes were made to O. Reg. 201/96 under the Ontario Drug Benefit Act (the “ODBA Regulation”) to establish 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 entire quantity of the listed drug product that is specified on the prescription to be dispensed at one time; or
  2. the maximum quantity permitted under section 18 of the ODBA Regulation 1(“Maximum Quantity”).

1 For most ODB recipients, the maximum quantity would be a supply sufficient for a 100-day course of treatment; for ODB recipients who are eligible for benefits under the Ontario Works program, the maximum quantity is a 35-day supply; 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.

In other words, the dispenser is required to dispense at one time the Maximum Quantity unless the prescriber has directed that a smaller quantity be dispensed. In cases where the prescriber has directed the dispensing of a reduced quantity (i.e. less than the Maximum Quantity), the ministry will provide payment for a maximum of two (2) dispensing fees per medication per recipient per calendar month.

Dispensers may also dispense less than the Maximum Quantity in cases where the dispenser has determined, in his or her professional opinion, that the ODB patient is incapable of managing his/her medication regimen as a result of physical, cognitive or sensory impairment. In cases where the dispenser has determined that reduced quantity dispensing is warranted due to patient impairment, the dispenser must maintain a written record of the reasons for this opinion, as well as a record of the authorization received from the ODB patient (or person presenting the prescription) for dispensing in reduced quantities. Under these circumstances, dispensers would receive payment under the ODB Program for no more than two (2) dispensing fees per medication per recipient per calendar month.

Although claims submitted for dispensing fees in excess of the monthly 2-fee limit are not eligible for payment under the ODB Program, dispensers would still receive payment for the drug benefit price plus any applicable markup. Pharmacists are encouraged to work with prescribers to facilitate the dispensing of the Maximum Quantity provided for under the ODBA Regulation.

The foregoing conditions do not apply if:

  • the ODB recipient is a resident of a long-term care home;
  • the ODB recipient is a resident of a Homes for Special Care (HSC) home (effective November 01, 2008); or
  • the medication being dispensed is one which has been designated by the Executive Officer for an exemption. These exempted medications are generally those that are normally prescribed for periods of short duration (e.g. antibiotics) or products where there is risk of abuse or diversion (e.g. narcotics and controlled drugs).
  • Exempted Medications

Exempted HSC Homes List [Excel]

Exempted LTC Homes Lists [Excel]

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