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Ontario Drug Benefit (ODB) stops paying for over 30 antibiotic
Ever since the introduction of Ontario’s Transparent Drug System for Patients Act, 2006,
continues to change, creating a 2-tier system between the private and public sector. Increases in the prices of
generics, combined with off-loading expenses to private payors and plan members, are increasing costs for
Canadian employers and their employees.
The most recent change occurred the week of January 14th when the Ontario Ministry of Health announced the
ODB would no longer pay for over 30 highly utilized antibiotic generic products.
On January 1, 2008, generic manufacturers raised their prices by 20-90% for 5 classes of antibiotics,
including Amoxicillin, Penicillin V, Cephalixin, Cloxacillin and Cefaclor.
In response to the significant price increases, the ODB Program changed the benefit status of over 30 highly
utilized, first line antibiotic generic products from “General Benefit” to “Not-a-Benefit”. A drug classified as “Not-a-Benefit” is not paid for by ODB, but is still listed on the ODB formulary and considered eligible for interchangeability with other listed products.
However, one generic drug product for each strength and dosage form, from each affected class of
antibiotics, remains listed as a “General Benefit” and is covered by ODB.
What does this mean?
All Ontario residents over the age of 65, including retirees and “active at work” employees, will no longer
have coverage through ODB for these commonly prescribed antibiotics.
Providers may be attempting to transfer the full cost of the claim to the private payor as would be the usual
practice for drugs that are not covered by ODB.
Because only one antibiotic generic product remains listed as a “General Benefit” and is covered by ODB, it
has compounded the issue since many pharmacies do not carry the lone generic product that is covered. Pharmacies that carry the covered products are exhausting their supplies.
Patients have the option to pay out-of-pocket for the non-covered drug, wait for the drug supply to come in
for the sole covered drug in that class, or have the prescription changed to a covered drug in another class.
How are costs being controlled?
Green Shield Canada is ensuring that all ODB claims are being adjudicated correctly (both electronic and
reimbursement processing) so that additional costs do not get passed on to you.
Private plans should not be first payor on any ODB claim. If ODB denies the claim for a “Not-a-Benefit” product, as your benefits administrator, we will also deny the
claim as an interchangeable product is still covered by ODB.
What has Green Shield Canada done?
Upon receiving the notice of these changes from the Ministry of Health, Green Shield Canada immediately
updated the eligibility status of these drugs to ensure the additional costs are not passed on to private plans.
Green Shield Canada will diligently monitor this situation and will provide information on any further
For more information
Please contact Green Shield Canada at 1.800.268.6613 or email@example.com for additional
A list of affected drugs can be found at the following website:
http://www.health.gov.on.ca/english/providers/program/drugs/edition_40.html About Green Shield Canada
As specialist in health and dental benefits programs and administration, Green Shield Canada is committed to
exceeding expectations by offering the highest quality of service and can be relied on to be responsive and
flexible. As Canada's only national not-for-profit health and dental benefits carrier, our goal is to serve our
clients by providing the most efficient customer service and the most effective benefits programs. greenshield.ca
Joint Plumbing Industry Board Plumbers Local Union No. 1 Trust Funds Welfare Fund Vacation and Holiday Fund Trade Education Fund Additional Security Benefit Fund 401(k) Savings Plan George W. Reilly, Co-Chairman - Labor Walter Saraceni, Administrator Vito Giachetti, Co-Chairman - Management Important Information Regarding Your Health Fund Benefits
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