Drug Funding Frequently Asked Questions

Several different payment sources exist for cancer drugs, depending on the medication, and how and where it is delivered.

Public Funding Options for Cancer Drugs in Ontario

These tables summarize the available public programs that fund the outpatient cost of cancer drugs.

Injectable drugs delivered in outpatient clinics in hospitals and cancer centres

Oral (“Take-Home Cancer Drugs”) and injectable drugs delivered through hospital or cancer centre outpatient pharmacies and community pharmacies

This is a summary only. For details on patient and drug eligibility criteria and funded drugs, please refer to each drug coverage programs’ policies.

¹ No cost to patients for eligible hospital- and cancer centre-administered injectable treatments
² Copayments and deductibles may apply
³ ODB eligible recipients include Ontarians who are aged 65+; those living in long-term care homes or homes for special care; enroled in the Home Care program; Ontario Works; Ontario Disability Support Program; and those registered in the Trillium Drug Program (TDP)

Note: For eligibility criteria, refer to each drug program's policy.

Cancer Drugs Provided in Hospitals and Cancer Centres

Some cancer drugs are covered by the hospital directly, as part of its global budget. Others may be covered by a certain funding program:

• Our New Drug Funding Program (NDFP) directly covers the cost of many newer and often very expensive injectable cancer drugs.
• Our 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.
• Our Case-By-Case Review Program considers requests for cancer drugs otherwise not funded, for patients with rare clinical circumstances that are immediately life-threatening.

In some situations, patients may use private insurance or pay directly for drugs that are not publicly funded. Some new and expensive injectable drugs not funded through the NDFP are available for private payment (either third-party insurance or self-pay), either out of province or at a private clinic. Some patients have these drugs administered at Ontario hospitals under the care of their own oncologists for private payment. Each hospital decides whether to administer unfunded injectable cancer drugs. The NDFP does not fund injectable cancer drugs administered in private clinics. Here are a few additional resources for information:

• Provis Infusion Clinic
• Provincial Working Group Report on the Provision of Unfunded IV Cancer Drugs

Cancer Drugs Taken at Home

Many Ontarians rely on private insurance for funding cancer drugs taken at home. However, several programs may provide cancer drug funding depending on the circumstances:

• The Ontario Drug Benefit (ODB) Program covers the cost of many drugs for seniors, those on social assistance and some other groups.
• Ontario residents with high drug costs in relation to their household income, who do not qualify under other programs, can apply for the Trillium Drug Program.
• In very special cases, the Exceptional Access Program may provide patient-specific funding to ODB-eligible recipients where drugs on the ODB list have been tried and do not work, or specific criteria have been met.
• Our 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 final funding decision is made by the Executive Officer of the Ministry of Health and Long-Term Care's (ministry) Ontario Public Drug Programs.

The recommendation about whether to fund a drug must be based on the degree of medical benefit it provides weighed against its cost. For cancer drugs, this is done through the pan-Canadian Oncology Drug Review (pCODR), which considers information and perspectives from manufacturers, oncologists, health economists and patients. The ministry and Cancer Care Ontario are partners in the process, along with other provincial ministries of health and cancer agencies. The pCODR process looks at the evidence of a drug's clinical and cost effectiveness, and makes a recommendation that is then reviewed by the CED. The CED then makes a drug funding recommendation to the Executive Officer in Ontario.

This process ensures the decisions are based on the best available scientific evidence.

Read more about Public Drug Funding and Administration in Canada.

Three steps are required before a cancer drug becomes a publicly funded benefit in Canada:

1. Health Canada provides federal market authorization to sell a drug. Products that receive a Notice of Compliance have met Health Canada's regulatory requirements for safety, effectiveness and quality.
2. The clinical and cost effectiveness of a drug is evaluated through the pan- Canadian Oncology Drug Review. This process considers information and perspectives from manufacturers, oncologists, economists and patients.
3. Each province or territory then makes its own funding decision considering affordability and other key issues.

Read more about Public Drug Funding and Administration in Canada or go to this site for more information on the review process:

• The pan-Canadian Oncology Drug Review

Health Canada and the provinces evaluate different aspects of a drug. Health Canada evaluates a product's safety and effectiveness, and approves drugs for sale and marketing in Canada. Although Health Canada approval (called Notice of Compliance) is a prerequisite for provincial funding, it does not compare the relative clinical benefits and cost effectiveness of a drug with those of other drugs that already are available and funded. This evaluation is the responsibility of each province that funds the drug.

Once a drug has been approved by Health Canada, it is evaluated through a pan-Canadian review process and a decision is made by each province individually. See Public Drug Funding and Administration in Canada to learn more about the process.

The pan-Canadian Oncology Drug Review publishes a list of drugs under review for clinical and cost effectiveness. The Ontario Public Drug Programs publishes a list of drugs under consideration for funding in Ontario. Visit these sites for more information:

• The pan-Canadian Oncology Drug Review – Find a review
• Ontario Public Drug Programs - Drug Submissions

No, the Special Access Programme is not a funding approval program. The program provides access to drugs that have not yet been approved for sale in Canada. Access is decided on a case-by-case basis for patients with serious or life-threatening conditions when conventional therapies have failed, are unsuitable or are unavailable. The cost of drugs obtained through the Special Access Programme may be covered by the patient, the hospital or an insurance plan. In some cases, the manufacturer may provide the drug free of charge.

Your doctor, pharmacist, or hospital’s drug access navigator can help identify available funding options. Cancer drugs may be covered by public funding programs (e.g., Ontario Drug Benefit, Trillium, New Drug Funding Program, Evidence Building Program, Case-by-Case Review Program, hospitals or by private pay (private insurance or patient).

Helpful Information

• New Drug Funding Program enrolment forms (for completion by physician or pharmacist)
• Ontario Drug Benefit Program
• Trillium Drug Program

The decision about whether to fund a cancer drug, as with any drug, is based on the degree of medical benefit it provides, weighed against overall cost.

There are several reasons why a new drug or indication may not receive funding approval:

• There is a lack of high-quality evidence of its effectiveness.
• The drug's medical benefit might be marginal.
• The drug may not offer enough of a benefit over treatments that are already available.
• The potential dangers or side effects of the drug may outweigh its benefits.
• The drug may not provide enough of a benefit to make its cost worthwhile.

Ontario's drug review process is in place to make sure that drug funding decisions are made (and Ontarians' healthcare dollars are spent) responsibly and fairly. This process ensures the decisions are based on the best available evidence of a drug's effectiveness and cost effectiveness.

To learn more about drug funding decisions, go to OPDP - EO Decisions and CED Recommendations.

In 2014/15, the New Drug Funding Program and Ontario Drug Benefit program combined covered more than $644-million in cancer drugs. This does not include money spent on cancer drugs by hospitals, and private payers such as individuals and private insurance companies.

Spending on cancer drugs will continue to grow for several reasons:

• Number of new drugs available
• Introduction of very expensive therapies
• Complexity and intensity of new cancer drugs
• Growing rate of cancer

Over the next 10 years (2014–2023), 834,750 more people in Ontario will be diagnosed with cancer. With improving survival and population growth and aging, this means ever increasing numbers of Ontarians will be living with cancer.

Drug prices are set by manufacturers. The price takes into account the costs behind the research and development of the drug, manufacturing costs, supply and demand, and other market and financial considerations. In Canada, drug prices are controlled by the Patented Medicine Prices Review Board, an independent quasi-judicial body established by parliament in 1987 under the Patent Act. The board limits the prices set by manufacturers for all non-prescription and prescription patented drugs sold in Canada. The board’s primary role is to protect Canadians against excessive pharmaceutical prices.

For more information on drug prices, please visit the Patented Medicine Prices Review Board.

We are partners in the pan-Canadian Oncology Drug Review, established in 2011, along with the Ontario Ministry of Health and Long-Term Care and other ministries of health and cancer agencies. The pan-Canadian Oncology Drug Review process ensures consistent and coordinated cancer drug funding recommendations across Canada.

The pan-Canadian Oncology Drug Review process considers the clinical and cost-effectiveness of cancer drugs. The recommendations are brought forward to the Executive Officer, which, in turn, makes the final recommendation to ministry’s Executive Officer about whether a drug should be funded.

We also administer the New Drug Funding Program, the Evidence Building Program and the Case-by-Case Review Program which are funded by the ministry.

Read more about Public Drug Funding and Administration in Canada.

Patients usually receive unfunded drugs either out of province, or at a private clinic for private payment. Some patients have these drugs infused in hospitals, under the care of their own oncologist, through some form of private payment. Each hospital must decide whether they will administer these drugs.

We and other cancer system stakeholders developed recommendations for the ministry in 2006 for a standard approach to providing new unfunded intravenous cancer drugs in Ontario hospitals for private payment.

The recommendations are available for review in this report: Provincial Working Group Report on the Provision of Unfunded IV Cancer Drugs