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If the retail price for a prescription drug is less than your copayment, the retail price should be charged. Employer Group. Covered outpatient formulary medications include: Tier 0: Healthcare reform drugs and Vaccines; Tier 1: Generic drugs on the VHP Drug Formulary Tier 2: Brand name drugs on the VHP Drug Formulary
Valley Health Plan recommends that you contact your health care provider directly for the most accurate and up-to-date demographic and participation information. If you are unable to find the provider or specialty you are searching for, you can contact Valley Health Plan Member Services Monday through Friday, 9:00 am-5:00 pm, at (888) 421-8444 (toll-free).
The Benefits and Coverage Handbook, also known as the Combined Evidence of Coverage or EOC, provides information about how to access services, member benefits, and your rights as a health care consumer. Benefits and coverage handbooks (EOC) for Covered California and IFP Plans 2025 Handbooks. English version ; 2024 Handbooks. English version
- Who Can Qualify
- What’s Covered
- What’s Not Covered
- Brand-Name vs. Generic Drugs
- Limited Use Drugs
- Biologic vs. Biosimilar Drugs
- What You Pay
- How to Get A Refund
- How to Get A Three-Month Supply
- Coverage During Travel
You will qualify for the Ontario Drug Benefit (ODB) program when you turn 65 years old. You will qualify before you reach that age because you’re: 1. living in a: 1.1. long-term care home 1.2. home for special care 1.3. Community Home for Opportunity 2. 24 years of age or younger and not covered by a private insurance plan 3. receiving professional...
The Ontario Drug Benefit program covers most of the cost of approximately 5,000prescription drug products. Search for covered drugs It also helps you pay for: 1. allergy shots and epinephrine injectable products (used in response to severe allergic reaction) 2. some products used in monitoring and testing for diabetes 3. some prescribed over-the-co...
The following will not be covered by the Ontario Drug Benefit program: 1. prescription drugs that you buy outside Ontario 2. drugs that are not listed on the official Ontario Drug Benefit Formulary/Comparative Drug Index, or are not approved by the Exceptional Access Program
When you search to check if a medication is covered, you may see that what you searched for is “equivalent to” another medication. One is the “brand" name and the other is “generic.” When a company develops a new drug, it will have the sole right to make (based on a formula) and sell the drug (under a brand name) for a certain period of time. That’...
If you search for a drugand it’s labelled as "Limited Use," that means it is covered only under special medical circumstances. When you’re prescribed one of these drugs, your doctor or nurse practitioner must confirm that your circumstances require treatment with a Limited Use drug by writing a three-digit code on your prescription, called the Reas...
Biologics
Biologicsare medicines made from substances found in living things. They are often used to treat diseases such as: 1. cancer 2. immune system disorders 3. diabetes
Biosimilars
A biosimilar drugis a highly similar version of a biologic drug. When a company develops a new biologic drug, that company has the sole right to make and sell the drug for a certain period of time. After that period ends, other companies can start producing their own version of the biologic drug. The version of the biologic drug that other companies produce is the biosimilar drug. Patients and health care providers can be confident that the quality, safety and patient benefits of the biosimil...
Coverage
As of December 29, 2023, the ODBprogram will no longer cover: 1. Remicade® (infliximab) 2. Enbrel® (etanercept) 3. Lantus® (insulin glargine) 4. Rituxan® (rituximab) 5. Humalog® (insulin lispro) 6. Humira® (adalimumab) 7. NovoRapid® (insulin aspart) 8. Copaxone® (glatiramer) If you’re taking any of these medications, you may need to transition to the biosimilar drug for ODBprogram to cover the cost. Speak to your doctor or nurse practitioner about this change during the transition period, beg...
What you pay depends on how you qualify for the Ontario Drug Benefit program: 1. Seniors 2. 24 years of age or younger and not covered by a private insurance plan 3. Living in a long-term care home, home for special care or a community home for opportunity 4. Receiving professional home and community care services 5. Receiving benefits from Ontario...
If you were covered by the Ontario Drug Benefit program and paid for a covered drug, submit your receipts online via the Ontario Drug Benefit Program Receipt Submission Form available on the Ontario Drug Benefit Program Online Applications and Forms website. You will be asked to include: 1. your Ontario Health card number 2. a copy of the official ...
Under the Ontario Drug Benefit program, you can request a three-month supply of some drugs used to treat certain chronic conditions, such as: 1. diabetes 2. high cholesterol 3. high blood pressure Getting a three-month supply of your prescription means you will pay co-payment fees less often. Talk to your pharmacist to find out which drugs qualify ...
For travel in Ontario
Your pharmacist can transfer your prescription to another pharmacy in Ontario, as long as: 1. your prescription has enough refills on it 2. you’re not refilling it too soon (within 10 days of end of supply) 3. your prescription is not for a controlled drug, controlled drug preparation or a narcotic (for example, oxycodone, Dilaudid, Xanax, diazepam)
For travel outside Ontario
If you’re planning to travel outside Ontario, you may be able to get a larger supply, but you can only do this once during the Ontario Drug Benefit program year – between August 1 and July 31. Keep in mind that prescriptions filled outside Ontario are not covered by the Ontario Drug Benefit program. Here is how it works: 1. if you have a supply of less than 30 days, you can get a travel supply of up to 200 days 2. if you have a supply of 30 days or more, you can get a 100-day supply
Get a travel supply of medication
To get your supply for travel out of Ontario, give your pharmacist either: 1. a letter (that you can write yourself) confirming you’re leaving the province for more than 100 days 2. a copy of your travel insurance policy showing you’re leaving the province for between 100 and 200 days You have to pay the deductible or co-payment amount for the extra supply.
The Ontario Drug Benefit (ODB) program covers most of the cost of approximately 5,000 medications you can search for on this page. You may be covered by Ontario Drug Benefit if you have OHIP coverage and are: eligible for OHIP+; age 65 or older; living in a long-term care home or a home for special care
live in Ontario; have a valid Ontario health card number; do not already qualify for the Ontario Drug Benefit program (for example, you are not enrolled in a program such as Ontario Works) do not have an insurance plan that pays for 100% of your drugs; spend about 4% or more of your after-tax household income on prescription-drug costs; What is ...
People also ask
Is my medication covered by the Ontario drug benefit program?
Do I need a health card to apply for Ontario drug benefit?
Are HIV / AIDS drugs covered by the Ontario drug benefit program?
How do I apply for the Ontario drug benefit program?
Who is covered by Ontario drug benefit (ODB)?
What products are covered by the Ontario drug benefit program?
The Trillium Drug Program (TDP) pays for eligible prescription drugs covered under the Ontario Drug Benefit (ODB) program, for residents of Ontario who: • Are between the ages of 25 and 64 years of age, or are 24 years of age and under and have a private plan • Have a valid Ontario Health number, and
