Many Ontario residents are surprised at the pharmacy counter when they learn that a medication is not covered by OHIP. This confusion is common—and understandable. While OHIP plays a critical role in Ontario’s healthcare system, it does not automatically pay for most prescription medications.
This guide explains what OHIP does not cover at the pharmacy, why certain medications are excluded, and what practical options patients have to reduce out‑of‑pocket costs in 2025.
What OHIP Actually Covers
OHIP primarily covers medical services, not medications. This includes:
- Doctor visits
- Hospital care
- Diagnostic tests
- Surgeries and procedures
Prescription drug coverage falls under separate provincial programs, which is why many medications are not paid for directly by OHIP.
Common Medications NOT Covered by OHIP
Below are categories of medications that are often not covered unless the patient qualifies for another program.
1. Most Prescription Medications for Adults (Ages 25–64)
If you are between 25 and 64 and do not qualify for a drug assistance program, most prescriptions must be paid for through:
- Private insurance
- Out‑of‑pocket payment
2. Weight Loss Medications
Medications prescribed solely for weight loss are generally not covered by OHIP or the Ontario Drug Benefit.
Examples include:
- Wegovy (semaglutide for weight loss)
- Saxenda
Coverage may apply only when a medication is prescribed for Type 2 diabetes, not for weight management alone.
3. Over‑the‑Counter (OTC) Medications
OHIP does not cover OTC medications, including:
- Pain relievers (acetaminophen, ibuprofen)
- Cold and flu products
- Allergy medications
- Vitamins and supplements
Some OTC items may be partially reimbursed through private insurance plans.
4. Fertility and Lifestyle‑Related Medications
Many medications related to fertility, sexual health, or lifestyle treatment are excluded unless specific clinical criteria are met.
5. Brand‑Name Drugs When a Generic Exists
If a generic version is available, drug plans usually cover only the generic cost. Patients choosing a brand‑name option may pay the difference.
Why These Medications Are Not Covered
Coverage decisions are based on:
- Cost‑effectiveness
- Clinical guidelines
- Budget limitations
- Availability of lower‑cost alternatives
These decisions are made at the provincial level and updated periodically.
Your Options If OHIP Does Not Cover Your Medication
The good news: lack of OHIP coverage does not mean you are out of options.
1. Ontario Drug Benefit (ODB)
You may qualify for ODB if you are:
- 65 or older
- On social assistance
- Living in long‑term care
ODB covers many prescription medications listed in the provincial formulary.
2. Trillium Drug Program
If medication costs are high relative to your household income, the Trillium Drug Program may help cover eligible prescriptions once a deductible is met.
This program is available to working individuals and families, not just seniors.
3. Private Insurance Plans
Employer or individual insurance plans may cover:
- Brand‑name medications
- Weight‑loss medications
- Fertility treatments
- Medical supplies
Coverage varies by plan.
4. Pharmacist‑Led Alternatives
Pharmacists can often help by:
- Recommending lower‑cost alternatives
- Switching to covered generics (with prescriber approval)
- Reviewing medication plans to reduce duplication
5. Manufacturer Assistance Programs
Some drug manufacturers offer:
- Co‑pay cards
- Patient assistance programs
- Temporary discounts
Your pharmacy can help determine eligibility.
How Your Pharmacist Can Help You Save
Pharmacists play a key role in navigating drug coverage. At Viva Health Pharmacy, support may include:
- Coverage reviews
- Help applying for Trillium
- Prescription transfers
- Medication reviews
- Refill synchronization
A short conversation can often lead to meaningful cost savings.
Not all medications are covered by OHIP—but that does not mean patients are without support. Understanding the system and exploring available programs can significantly reduce out‑of‑pocket costs.
If you have questions about medication coverage, eligibility programs, or cost‑saving options, speak with your pharmacist. The team at Viva Health Pharmacy in Richmond Hill is here to help you navigate your options with clarity and care.
