How Do Government Programs and Private Benefit Plans Integrate?
Do government programs and private benefit plans integrate?
In short, the answer is yes however, depending upon the program “do I qualify?” may be the more appropriate question.
Many of my clients ask me this question and there is not a straightforward answer. There are many programs available through various levels of government but for the sake of time and simplicity, I will only focus on the most utilized and often least understood. Several provinces have variations of these but will focus on Ontario’s programs as this represents the lions’ share of my audience.
Ontario Drug Benefit (ODB)
If you are a senior residing in Ontario, you will qualify. There are approximately 4,400 drugs on the ODB formulary. So any private plans with retirees or employees over the age of 65, should automatically qualify if the drug falls within the drug formulary.
Trillium Drug Benefit (TDB)
This is probably the program that most companies have confusion about and represents the largest potential financial upside to a private plan.
You qualify if you:
- Ontario resident
- Possess an Ontario Health card
And you are not covered under TDP as a:
- A senior over the age of 65
- someone who receives financial help through Ontario Works or the Ontario Disability Support Program
- a resident of a Long-Term Care home or Home for Special Care
- You don’t have private health insurance or your private insurance does not cover 100% of your prescription drug costs.
This last point is the kicker for most companies. So if you have a drug plan that does not have a drug cap or pay 100% of the cost of the plan, you should qualify.