Financial help available to make prescription drugs more accessible for more Ontarians
Prescription affordability consistently emerges as a major barrier in our work. Many patients report making difficult choices between filling their medications and paying rent or other essential expenses. Provincial drug programs and benefits exist, but they are not always easy to navigate.
What difference can a financial intervention, with support, make on someone’s health?
The GreenShield Cares Essential Medicines program is a drug benefit plan that provides $1,000 per year in prescription coverage through Green Shield Pharmacy for Ontarians, with no out-of-pocket costs, co-pays, or deductibles. It is designed for those who do not have private prescription drug coverage. The program works alongside benefits such as Ontario’s Trillium Drug Program and other provincial drug programs (e.g., Ontario Works, Ontario Disability Support Program, Ontario Drug Benefit Program), to fill gaps where coverage or eligibility doesn’t exist.
The project aims to reduce financial barriers for those who cannot afford their prescribed medicines. It is a drug benefit plan that provides coverage for eligible prescription drug costs at no out-of-pocket cost to eligible residents of Ontario, with no co-pays or deductibles.
It can be used by people who may be eligible for provincial benefits but cannot afford the deductible. According to Ontario Health: “For most people, the deductible for the Trillium Drug Program equals about 4% of the household income after taxes.” That can be out of reach for many Ontarians living in poverty.
In addition to a lack of private or public access to prescription benefit plans, to be eligible, you must be employed, have a combined household net income below the program threshold, be between 25 and 64 years old, and be a Canadian citizen or a permanent resident who resides in the province of Ontario. The GreenShield program website has more detailed information about eligibility requirements.
The complexities of coverage
Canadian citizens or permanent residents tend to have OHIP. In practice, if a client has OHIP but no drug benefits/coverage, healthcare providers prefer to refer the client to apply for Ontario drug programs first, as they provide more/better coverage than GreenShield. This can create challenges for a program like this.
Application processes can be overwhelming, particularly for individuals balancing medication costs against other financial priorities.
The GreenShield program covers the costs of some medications, but not all. A GreenShield pharmacist can review your medications to determine which program will serve you best. Medications are dispensed by GreenShield Pharmacy and shipped at no cost directly to the patient’s home.
Coverage is available for one year (12 months from coverage start date). You can reapply if you still meet the eligibility criteria.
Navigating the benefits – this is where we come in
Providing application and navigation support, along with ongoing follow-up, enables other staff to reduce the stress of navigating the system independently. Ontarians can apply directly to GreenShield’s program. However, like many social and income support programs, guidance and support can be useful.
For example, those eligible will likely have OHIP coverage, but may not have private prescription benefits in their workplace, or be eligible for Ontario government benefit programs, or be able to afforce program deductibles. The program isn’t trying to duplicate coverage where it already exists. For example, an age limit of 25 to 64 aligns with existing Ontario programs. OHIP+ exists for anyone age 24 or younger. The Ontario Drug Program (ODB) covers Ontarians aged 65+.
Any application process, especially for someone weighing choices about medication vs other financial choices, can feel overwhelming, confusing, and cumbersome. By offering application and navigation support, and following up to track health outcomes, health promoters, social prescribers, researchers, or nursing staff can help remove the stress involved of navigating the system alone.
Through our provincial umbrella organization, the Alliance for Healthier Communities, Access Alliance is piloting the program in our primary care services. The goal of this pilot is to support our patients’ access to the program if they are not eligible for other benefits, as well as to understand the available scope of coverage (many, but not all, medications are eligible to be covered). Support for implementation includes information sessions for pilot partners, technical guides to help implement the pilot, and shared best practices among partners. We’ll be evaluating what the impact of participating in the program has on their access to prescription medication and overall health outcomes.
It’s about more than medication
The project aims to improve the overall quality of life for patients. As part of the program, we will be using a patient-reported outcome measure to determine the impact of the program on a patient’s physical and mental health status over time.
Through the pilot, we’ll also ensure that information about their coverage is captured in our medical records. Having this information can help us as primary care providers to help patients manage their medication as part of their overall care, which can be a gap. We learned more about this in our work to better understand what Seniors need to know and communicate about medications.
We have already heard from some providers that if a patient is OHIP-covered, they may prefer to have their patient apply for Ontario plans first because they provide more coverage than GreenShield. It’s interesting to note that determining a patient’s eligibility for existing Ontario government drug programs is not always a conversation that comes up. You might wonder why a conversation about that eligibility hasn’t already occurred between a provider and patient. It’s a great question.
A seemingly small intervention can make a big difference for health and well-being
Perhaps one of the unintentional by-products of an intentional project like this, is that conversations about medication affordability will become more frequent and normalized, alongside support for patients in navigating benefit programs they can access to help reduce their medication costs.
As we progress on this interesting project, we will share both our findings and those of our Alliance partner evaluation findings regarding its impact on access to affordable medication and health outcomes. This will include examining the impact of providing short-term (1 year) access to benefit coverage which are eventually removed unless the patient reapplies and is reassessed for continued eligibility.
An important systemic question might also be addressed by this pilot: if a targeted $1,000 intervention can stabilize the health trajectory and quality of life for Ontario’s working poor, why is this not already the national standard?
Related Access Alliance work
Understanding what Seniors need to know and communicate about medications – a health care system reality check
This joint project between the Access Alliance Research Department and the Open Door project focused on creating a new presentation for seniors about medication, medication compliance, medication use, medication reconciliation and review, why it is important to share accurate information about medication with providers, etc. We set out to build a workshop and simple tools to help seniors better understand and manage their medications. The 95 seniors we spoke to give us a health care system reality check. We learned how seniors feel about medication and their preferred relationship with health care practitioners.