Hepatitis C: An In-Depth Guide

Ontario

Prescription Drug Programs

General information on drug coverage and benefit programs offered by the provincial, territorial and federal governments can be found here.

Coverage for Hepatitis C Medications

The Ontario Drug Benefit Program (ODB) and the Trillium Drug Program (TDP) are the two main programs that assist Ontario residents with covering the costs of expensive prescription drugs and may be able to help cover the high cost of hepatitis C treatment medications.

What is the Trillium Drug Program?

The TDP provides drug benefits to Ontarians who have high drug costs in relation to their household income. Residents who do not qualify for any of the other programs can apply for the TDP. An annual deductible and co-payments (based on household income) apply to all recipients of the TDP, which is paid in four installments throughout the year.

What is the Ontario Drug Benefit Program?

Individuals who receive social assistance, either through Ontario Works (OW) or the Ontario Disability Support Program (ODSP), may be eligible for prescription drug coverage through the ODB.

How do you apply for coverage of Hep C meds?

In Ontario, the following hepatitis C medications are eligible for coverage as Limited use drug products:

  • asunaprevir and daclatasvir
  • daclatasvir and sofosbuvir
  • Epclusa (velpatasvir and sofosbuvir)
  • Harvoni (ledipasvir and sofosbuvir)
  • sofosbuvir (taken in combination with  ribavirin)
  • Zepatier (elbasvir and grazoprevir)

With limited use drug products, a person’s doctor will determine which medications is appropriate for them and if they qualify to have this treatment covered by the provincial drug plan.  Each limited use drug product has a specific code that the doctor will write on the person’s prescription.  The pharmacist then fills the prescription and will be reimbursed by the government program.

In general, hepatitis C medications no longer need to be approved under the Exceptional Access Program. The one exception to this is if a person needs to be retreated.

Some of the factors that may be considered when a doctor makes decisions about hepatitis C medications include:

  • a positive HCV RNA test
  • HCV genotype
  • level of fibrosis
  • child-Pugh score or level of cirrhosis
  • whether or not an individual is living with chronic hepatitis C
  • whether or not an individual is treatment naïve
  • whether or not a person has been previously treated and what their response to treatment was
  • HIV status

In Ontario, a person needs to have a certain level of liver injury (fibrosis stage 2) to qualify for treatment coverage. However, a person does not need to meet this requirement if they have one or more of the following issues:

  • Coinfection with HIV or hepatitis B
  • Fatty liver disease
  • Has previously had an organ transplant
  • other health problems caused by hepatitis C that affect parts of the body other than the liver (extra-hepatic manifestations)
  • Chronic kidney disease (stage 3, 4 or 5)
  • Diabetes and receiving treatment anti-diabetic mediations
  • Are of child bearing age and are planning to get pregnant within the next 12 months

The full criteria for funding of hepatitis C medications can be found in the Ontario Drug Benefit Formulary/Comparative Drug Index.

What about coverage under the Non-Insured Health Benefits program?

Registered First Nations and recognized Inuit people may be able to access coverage for their hepatitis C medications through the Non-Insured Health Benefits (NIHB) program. People can contact NIHB by phone or mail at:

Non-Insured Health Benefits – Ontario Region
Health Canada
Sir Charles Tupper Building
2720 Riverside Drive, 4th Floor
Address Locator : 6604E
Ottawa, Ontario
K1A 0K9
 
Toll-free: 1-800-640-0642

 

Some programs can be accessed by all Canadians. Examples include:

Private health insurance

Some health insurance policies offered through private insurance companies include coverage for prescription drugs. These programs often have their own deductible, or co-pay fee, and may have yearly maximums for prescription drugs.

Programs offered by pharmaceutical companies

The pharmaceutical companies that make Hep C medications have programs to help people complete treatment. Merck has the Merck Care program for people taking peg-interferon alpha-2b (known as Pegetron). Hoffman-La Roche has the Pegassist program for people taking peg-interferon alpha-2a (known as Pegasys). Vertex has the Incivek Care program for people taking telaprevir (known as Incivek). Gilead Sciences has the Momentum Support program for people taking sofosbuvir (known as Sovaldi).

These programs have phone support for people on treatment, and part of this support is helping people to access the funding necessary to cover treatment costs. These programs can inform patients about local, provincial, and federal government programs for accessing treatment and can help the patient find out ways to maximize any public funding or private medical insurance (including the appeals process, if the patient also has a supportive doctor). If a person is eligible, some programs can help cover the insurance company co-pay fee, provincial or territorial plan's deductible, and a number of other expenses, depending on a person's specific situation.

Janssen has the Galexos: BioAdvance Patient Support Program for people taking simeprevir (known as Galexos).

AbbVie has the AbbVie Care Program for people taking Holkira Pak.

For more information, contact:

 Pegassist Program

 1-877-PEGASYS (1-877-734-2797)

 Merck Care Program

 1-866-872-5773

 Incivek Care Program

 1-877-574-4298

Momentum Support Program 

1-855-447-7977

Galexos: BioAdvance Patient Support Program

1-855-512-3740

AbbVie Care

1-844-471-2273

People who contracted hepatitis C from a blood transfusion between 1986 and 1990 may be eligible to have hepatitis C treatment expenses covered by the Hepatitis C January 1, 1986 - July 1, 1990 Class Actions Settlement. To learn more about these programs, see Compensation.

Revised 2014.