Prescription drugs play a vital role in the health of millions of Ontarians, but the cost of medication can add up quickly. Whether you’re managing a chronic condition or filling a short-term prescription, it helps to know who pays — OHIP or your private insurance plan.
Understanding how public and private drug coverage work in Ontario can help you make smarter financial and health decisions. This article breaks down how each system works, who qualifies, and how your local pharmacy in Richmond Hill can help you coordinate both.
How Public Prescription Coverage Works in Ontario
The Ontario Health Insurance Plan (OHIP) pays for most medical and hospital services, but not for most prescription drugs. Instead, medication coverage falls under the Ontario Drug Benefit (ODB) system — a program that provides financial help to specific groups of residents.
You qualify for ODB coverage if you are:
- 65 years of age or older
- Receiving Ontario Works (OW) or Ontario Disability Support Program (ODSP) benefits
- Living in a long-term care or special care home
- Receiving professional home-care services
- Enrolled in the Trillium Drug Program (for households whose drug costs are high compared to income)
If you qualify, ODB covers thousands of medications listed on the Ontario Formulary, from antibiotics to insulin to certain diabetes medications such as Ozempic (for approved use in Type 2 diabetes).
You may have to pay:
- $0–$6.11 per prescription if you’re a senior with lower income
- $100 annual deductible + $6.11 per prescription if you earn more
This makes ODB one of the most comprehensive public drug programs in Canada.
How Private Insurance Works
Private insurance — either through an employer or a personal plan — offers coverage for medications not listed on ODBand provides broader flexibility.
Private plans typically include:
- Coverage for newer or non-Formulary drugs (like Wegovy or Saxenda)
- Higher brand-name coverage limits
- Additional services such as dental, vision, or physiotherapy
- Partial to full reimbursement (usually 70–100% of drug costs)
Private insurers like Sun Life, Manulife, Canada Life, and Green Shield process claims electronically through pharmacies, making the process quick and seamless.
Most plans have a deductible or co-pay, but the savings can be substantial for those on high-cost or specialty medications.
Public vs Private Insurance: What’s the Difference?
| Feature | Public Coverage (OHIP/ODB/Trillium) | Private Coverage (Employer or Individual) |
|---|---|---|
| Eligibility | Based on age, income, or disability | Based on employment or personal enrollment |
| Covered Drugs | Ontario Formulary (limited list) | Broader, includes non-Formulary drugs |
| Cost to Patient | Minimal or none | Premiums + possible co-pay |
| Claim Process | Handled through pharmacy with health card | Handled via insurance card or mobile app |
| Examples of Covered Drugs | Metformin, Insulin, Ozempic (for diabetes) | Wegovy, Saxenda, Contrave (for weight loss) |
Both systems can complement each other when managed correctly.
Can You Use Both Public and Private Insurance?
Yes — and many Ontarians do.
When you have both, one plan acts as the primary payer and the other as secondary coverage.
For example:
- Your private insurance may cover part of a prescription.
- The Trillium Drug Program may cover the remaining balance.
Pharmacies can coordinate both automatically at checkout, ensuring you pay the lowest amount possible.
How to Check What’s Covered
- Bring your insurance cards (both OHIP and private) to your pharmacy.
- Ask your pharmacist to run a test claim before filling your prescription.
- Check the Ontario Drug Benefit Formulary online for public coverage.
- Contact your insurance provider or check your benefits portal for exclusions or annual limits.
If a drug isn’t covered, your doctor can often provide a therapeutic alternative that is.
Common Scenarios
Scenario 1:
A senior over 65 with private insurance.
→ ODB covers most medications. Private insurance may pay for brand names or additional supplies like glucose sensors.
Scenario 2:
A 45-year-old on a GLP-1 medication like Ozempic for weight loss.
→ OHIP doesn’t cover it unless prescribed for Type 2 diabetes, but a private plan might.
Scenario 3:
A family with high medication costs.
→ The Trillium Drug Program can help once annual drug expenses exceed a set percentage of household income.
How Pharmacies Help You Coordinate Coverage
At Viva Health Pharmacy in Richmond Hill, pharmacists help patients:
- Understand public and private coverage options
- Submit and track claims through both plans
- Apply for Trillium Drug Program support
- Access manufacturer assistance programs for costly drugs
- Find lower-cost generic or biosimilar options
With direct billing and knowledgeable staff, patients often save hundreds annually simply by optimizing their coverage.
The Role of Trillium Drug Program
Many Ontarians fall into a “coverage gap” — not low-income enough for ODB, but not fully covered by private insurance.
The Trillium Drug Program bridges this gap by limiting the amount you pay based on your income.
- Deductible: about 4% of household income per year
- After that, most eligible drugs are covered for the rest of the year
Pharmacies can guide you through the application process and help gather the necessary forms.
Ontario’s hybrid healthcare system gives residents access to essential medications through both public and private channels.
The key is knowing how to combine them strategically — and your pharmacist can make that easy.
Whether you’re managing diabetes, hypertension, or starting a new medication like Ozempic, a pharmacist can ensure your prescriptions are filled correctly, safely, and affordably.
For personalized guidance on how to coordinate your coverage, visit Viva Health Pharmacy in Richmond Hill. Our experienced pharmacists can verify your eligibility, submit claims, and help you get the most from every plan you have.
