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Cancer Drug Coverage, Funding and Reimbursement

Cancer drugs are typically paid for by the government, Ontario Health, or hospitals/cancer centres. There are different programs for drugs given in the hospital (e.g., IV chemotherapy) or taken at home (e.g., oral cancer drugs). Where a combination of hospital-administered and take-home cancer drugs are prescribed, your health care team may need to apply to multiple programs.

All First Nations, Inuit, Métis, and urban Indigenous peoples living in Ontario can apply to any of Ontario’s cancer drug coverage programs.

A valid Ontario health card number is needed to apply.

 

 

Finding Drug Coverage

If you are a patient looking for drug coverage information, speak to your health care team for more information. Your doctor, pharmacist or hospital’s drug access navigator can help identify funding options for you. Your health care team may need to submit application forms and confirm that your drug is covered before your treatment begins.

If your drug is not covered by a public drug program:

  • Check for coverage with your private insurance
  • Check if the drug company offers a patient support program
  • Ask your health care team about participating in a clinical trial

Ask your health care team about other therapies that may work well to treat your disease

Coverage for Cancer Drugs Provided in Hospitals /Cancer Centres

Ontario Health administers several programs to assist hospitals in covering the cost of injectable drug(s) given in outpatient hospital/cancer centre clinics.

Applicants must have a valid Ontario health card and meet specific eligibility criteria to be covered.

  • The New Drug Funding Program (NDFP) directly covers the cost of many newer and often very expensive injectable cancer drugs.
  • The Evidence Building Program covers the cost of cancer drugs in situations where data is collected to answer an evidence gap, to evaluate clinical benefit and to confirm overall value.
  • The Case-By-Case Review Program considers requests for cancer drugs otherwise not funded, for patients with rare clinical circumstances that are immediately life-threatening.
  • The Systemic Treatment- Quality Based Procedures provides bundled funding to hospitals for evidence-informed cancer regimens. This bundled funding includes administration costs and low-cost injectable drugs.
  • The CAR T-cell Therapy Program provides funding to hospitals to administer Chimeric Antigen Receptor (CAR) T-cell Therapy for patients that meet specific clinical criteria.
  • The High-Cost Therapy Funding Program funds high cost injectable or oral drugs given primarily in inpatient units or specialized settings.

Cancer Drugs Taken at Home

The Ministry of Health pays for many take-home cancer drugs through several programs:

  • The Ontario Drug Benefit (ODB) Program covers the cost of many drugs for people as soon as they turn 65 years old. You may also qualify if you are:
  • For drugs not covered by the Ontario Drug Benefit (ODB) program, your doctor or nurse can apply to the Exceptional Access Program (EAP) on your behalf. To receive coverage, you must meet specific clinical criteria and qualify for ODB.
  • The Case-By-Case Review Program considers requests for cancer drugs otherwise not funded, for patients with rare clinical circumstances that are immediately life-threatening. To receive coverage for take-home cancer drugs, you must qualify for benefits under the Ontario Drug Benefit program.

Coverage for First Nations, Inuit, Métis and urban Indigenous Peoples

All First Nations, Inuit, Métis, and urban Indigenous peoples who live in Ontario are eligible for coverage under OHIP and for public drug coverage programs available to people living in Ontario. A valid OHIP number is needed to access services in the hospital and to apply to Ontario’s drug coverage programs.

In some cases, individuals may need to apply to the Non-Insured Health Benefit Program (NIHB). This program provides eligible First Nations and Inuit clients with coverage for a range of health benefits that are not covered through other social programs, private insurance plans, or provincial or territorial health insurance. For eligibility details, visit the NIHB website.

The NIHB does not provide coverage for cancer drugs administered in hospital. Please speak with your health care team about coverage options.

See this reference sheet for more information: Cancer Drug Funding for First Nations, Inuit, Métis and urban Indigenous People

Other Public Coverage Programs

Learn more about other coverage programs that may offer financial assistance to patients receiving cancer therapies.

  • Workplace Safety Insurance Board (WSIB): Provides wage-loss benefits, medical coverage and support to people living in Ontario suffering from a work-related injury or illness. If you have a work-related cancer (e.g., mesothelioma), speak with your health care team about applying to this program. People living with mesothelioma can also visit Work-Related Mesothelioma: Getting Help from WSIB
  • Interim Federal Health Program: Provides temporary coverage of health care benefits including prescription drug coverage to refugees, refugee claimants and certain other groups who are not eligible for provincial or territorial health insurance (e.g., OHIP).

Clinical Trials

Your doctor may suggest participating in a clinical trial where you may be given an experimental treatment. Clinical trials are something you volunteer to do. Visit the Canadian Cancer Society website to learn more about participating in a clinical trial.

Health care providers wanting to learn more about cancer drug reimbursement policies for patients participating in clinical trials can visit Systemic Treatment Clinical Trials.