Summary: HIV antiretroviral medication coverage in Canada

• British Columbia Centre for Excellence in HIV/AIDS [BC-CfE]
• Drug Treatment Program [DTP]
• Pharmacare
• Federal Public Drug Benefit Programs

• ARV and other drugs for the management of HIV/AIDS are provided at no cost to medically eligible clients through the BC-CfE
• No out-of-pocket costs, regardless of age or income
• The program is funded by the provincial government [PharmaCare] and distributes medication based on guidelines set by the Committee for Drug Evaluation and Therapy [CDET]
• If private insurance covers an ARV not covered by the province, the client can be part of both programs
• Most private insurance will not cover ARV costs that are covered by the province

BC plan eligibility

• Must have documented HIV infection and be a BC resident with Medical Services Plan coverage
• Initial enrollment requires the submission of ARV Drug Treatment enrolment forms by the physician

• Alberta Health Care Insurance Plan [AHCIP]
• Specialized High-Cost Drug Program
• Federal Public Drug Benefit Programs

AHCIP eligibility
Specialized High-Cost Drug Program

• Must be an Alberta resident, registered for AHCIP and require an "eligible high-cost drug to treat an eligible medication condition" [this includes HIV]
• Once HIV is diagnosed, the client is referred to either the Northern Alberta HIV Program [located in Edmonton] or the Southern Alberta HIV program [located in Calgary]
• ARV medications are prescribed by specialty personnel [medical doctor, nurse practitioner, pharmacist]

• The Saskatchewan Drug Plan
• Exceptional Drug Status Program [EDS]
• Federal Public Drug Benefit Programs

• Full coverage of ARV medication is offered at no cost, regardless of age or income. There is no deductible or co-payment.
• HIV medications are offered through the Exceptional Drug Status [EDS] Program.
• Initial prescription or changes to antiretroviral therapy must be prescribed by an Infectious Diseases Physician or an approved ARV prescriber [physician, nurse practitioner, pharmacist with specific additional training].
• Prescriptions for ARV can be renewed by any prescriber.
• Once a person is diagnosed with HIV, an automatic referral is made to the most appropriate Infectious Diseases Clinic/HIV program. The main clinics are in: Regina, Saskatoon, and Prince Albert.
• HIV information for Health Care Providers

Note: Regarding other drug coverage in Saskatchewan [Not ARV, but may relate to HIV/AIDS management], there are additional programs:

• Special Support Program: an income-tested program that helps residents with their drug costs in relation to their income. There is a co-payment and a deductible. This plan only covers drugs under the Saskatchewan Formulary and does not include EDS medications.
• Children's Drug Plan: Co-payment is up to $25 per prescription.
• Seniors Drug Plan: Age ≥65yr with income $69,741 for 2021 tax year; no deductible. Co-payment is up to $25 per prescription.
• Supplementary Health Benefits: provides non-insured health service to government wards, inmates of provincial correctional institutions, residents of special care facilities who are eligible for the Senior's Income Plan, and those enrolled in income support programs [SAID, SIS]

Eligibility for Saskatchewan health benefits

• Must be a Saskatchewan resident and have a Saskatchewan Health Card
• Must also have Exceptional Drug Status [EDS] approval. For approval, ARV treatment must be initiated by an Infectious Disease physician or by an approved ARV prescriber.

• Manitoba Pharmacare Program
• Manitoba ART Medication Program
• Federal Public Drug Benefit Programs

Manitoba Pharmacare Program

• To be eligible for Manitoba's public plan, a deductible must be paid. The deductible is based on income [annual deductible is 3.23 - 7.28% of adjusted family income]. Minimum yearly deductible is $100. The Pharmacare benefit year is April 1 to March 31. The Pharmacare Deductible Estimator will calculate the yearly deductible.
• Once the deductible is paid, Pharmacare will pay 100% of eligible prescription drug expenses.

HIV antiretroviral treatment [ART] Program

• This program is for those requiring additional financial help
• The prescriber must fill out the HIV Medication Program Eligibility Form
• The program is intended for those who are experiencing significant financial barriers to treatment and do not have other drug insurance [i.e., no private insurance or federal drug program]. This program is not intended to provide coverage indefinitely. Enrollment is reviewed regularly.

Access to this program will facilitate timely access to a prescribed ART regimen and will allow clients and their caregivers more time to explore and establish long-term options for medication coverage.

• Clients in the process of enrolling in Manitoba Pharmacare [or Deductible Installment Payment program]: 3 months of drug coverage will be provided. Once Pharmacare enrollment is complete, costs paid through this program will go towards the client's deductible for the first year of treatment.
• Clients that cannot enroll in Manitoba Pharmacare [i.e., new resident/immigration status]: One-year coverage of ART is provided and will be reviewed annually.

Eligibility for Manitoba Health Care Coverage

• Must be a Canadian citizen or have immigration status.
• Must have a permanent residence in Manitoba and reside in the province at least 6 months/year.

• OHIP+, Trillium Drug Program, Ontario Drug Benefit Program
• Ontario Works, Ontario Disability Support Program
• Federal Public Drug Benefit Programs

Coverage depends on age, income, disability and/or whether the client has private insurance coverage

OHIP + eligibility [Ages ≤ 24 years]

• For those ≤ 24 years without private insurance [if partial insurance, then does not qualify].
• No enrollment is required [beyond having an OHIP card].
• No deductible/co-payment or out-of-pocket costs.

Trillium Drug Program [Ages 25 - 64 years of age]

• Eligibility criteria: Ontario resident, have no or insufficient private insurance, have a valid OHIP card, not be eligible for drug coverage under ODB and be 25 to 64 years of age.
• This income-based program is for Ontario residents who have high prescription costs relative to their net household income.
• The deductible is ≈ 4% of income after taxes, the co-payment is $2 per prescription
• The process is: pay [out-of-pocket] for drug or use private insurance. What isn't covered [or if no private insurance], apply to Trillium Drug program [will receive remaining coverage minus the deductible]

Ontario Drug Benefit [ODB] Program [Ages ≥ 65 years]

• Eligibility criteria include the following: ≥ 65 years; a resident of long-term care, enrolled in the Home Care Program and receiving OW/ODSP
• $2 co-payment for each prescription [no deductible]
• Note: all those ≥ 65 are automatically enrolled in ODB
• ≥ 65 years with income ≤$22,200 [single] or ≤ $37,100 [with spouse] = no deductible, $2.00 co-payment
• ≥ 65 years with income >$22,200 [single] or >$ 37,100 [with spouse] = $100 deductible, $6.11 co-payment

Ontario Works [OW] and Ontario Disability Support Program [ODSP]
Eligibility criteria are:

• OW: ≥ 16 years, Ontario resident, in financial need
• ODSP: ≥ 18 years, Ontario resident, in financial need, have a disability
• $2 co-payment for each prescription

• Regie de l'assurance maladie du Quebec [RAMQ]
• Quebec Health Insurance Plan
• Public Prescription Drug Insurance Plan
• Federal Public Drug Benefit Programs

• All Quebec residents must have drug coverage - either through private insurance or RAMQ.
• Private insurance companies in Quebec must, at a minimum, cover what RAMQ covers [so there really shouldn't be a situation where private insurance offers partial coverage compared to RAMQ]. Private insurance is used first [if available]

RAMQ administers the Québec Health Insurance Plan ["the public plan"]. There are deductibles and co-payments

• Yearly premium collected by Revenu Québec; based on family net income [up to $710 per person/year]
• Deductible: $22.25/month
• Co-insurance payment [% of the cost of covered drugs that you pay once deductible is paid] = 35%.
• MAX contribution $96.74/month or $1161/yr.
• For those ≥65 years receiving 1-93% GIC*: MAX $55.08/month or $661/year
• Process: Drugs are paid by the client until the deductible is paid, then 100% coverage of eligible medications. The deductible year is Jan 1 to Dec 31. Quebec rates are in effect from July 1 to June 30.

There are no costs for the following populations [assuming no private insurance]

• Holders of a claim slip (e.g., patient receiving social assistance)
• Children of persons covered under the public plan
• Persons with functional impairment
• Persons ≥ 65 years receiving 94-100% of GIC*

[Note: GIC = guaranteed income support]

Quebec Plan eligibility

• Eligible if no private insurance, <18 years living in Quebec whose parents don't have private insurance, <18 years temporarily living in Quebec for >6 months, those aged ≥65 years who do not have private insurance; recipients of last-resort financial assistance and certain holders of claim slips

• New Brunswick Prescription Drug Plan
• HIV/AIDS Prescription Drug Program [Plan U]
• Federal Public Drug Benefit Programs

• Must apply to the HIV/AIDS Prescription Drug Plan for drug coverage.
• If the client has existing drug coverage with another drug plan, the client must submit a letter from their existing drug plan confirming that the required drugs are not listed on their private insurance plan.
• If the client has no private insurance, they can obtain drug coverage [Plan U]

Within Plan U:

• The HIV/AIDS Plan has an annual registration fee of $50 and a co-payment.
• Co-payment is 20% of the prescription cost, up to a maximum of $20.
• The co-payment ceiling is $500 per family unit per plan year.
• If the client has a health card for prescription drugs through the department of social services, the co-payment is $4 per prescription for adults and $2 for children.

New Brunswick plan eligibility

• Must be a New Brunswick resident with an active Medicare card, be diagnosed with HIV and registered into the plan by a medical doctor

• Nova Scotia Family Pharmacare Program [previously called High-Cost Drug Program]
• Federal Public Drug Benefit Programs

• Use private insurance first. ARV covered by private insurance can be filled at any pharmacy in the province. Note that if private insurance doesn't cover all drugs, the client is eligible to obtain ARVs through the public plan.
• If no private insurance, ARV medications are covered under the Family Pharmacare Program public plan.
• No deductible or co-payment [if private insurance has a co-payment, Pharmacare will pay this as well].
• Under the public plan, prescriptions must be filled in Halifax [at QEII Pharmacy]. The client does not need to qualify based on income to use this program. However, there is a user fee [$11.95 for 3-month supply per drug]. If the client qualifies for income assistance, then the user fee may be reimbursed as well [through ESIA- employment support and income assistance program].
• HIV Clinic QEII Patient & Family guide 2021

Nova Scotia Pharmacare eligibility

Must be a NS resident, have a valid Nova Scotia Health card and agree to:

• Family income verification through CRA and
• Provide family size information each year.

Note that while there may be deductibles [based on family size and annual income] for other medications, this does not apply to ARV medications.

• HIV Drug Program
• Federal Public Drug Benefit Programs

• There are no deductibles, co-payments, or out-of-pocket costs, regardless of age/income
• A medical doctor or nurse practitioner must submit a request for registration into the HIV Drug Program to the Chief Public Health Office. Once approved, the client's name will be forwarded to The Provincial Pharmacy [Fitzroy Street, Charlottetown]
• ARV medications can be picked up at The Provincial Pharmacy. If unable to do so, the client can pay the courier costs and have the medication delivered to their home.

Prince Edward Island [PEI] plan eligibility is as follows:
Must have a PEI health card and either:

• Test positive for HIV, or
• Be diagnosed with AIDS

• The Newfoundland and Labrador Prescription Drug Plan [NLPDP]
• Federal Public Drug Benefit Programs

The NLPDP may provide financial assistance for the purchase of eligible medications. ARV coverage through the NLPDP plans is provided based on income. A provincial summary outlines the 4 plans.

Note that private insurance is used first. NLPDP is the payer of last resort. Foundation Plan

• This plan provides 100% coverage of eligible prescriptions for those who are in greatest need. This includes persons and families in receipt of income support benefits through the Department of Advanced Education and Skills and certain individuals receiving services through the regional health authorities, including children in the care of Child, Youth and Family Services and individuals in supervised care. No application is necessary.
• A Prescription Drug Program card is automatically issued when the Department of Health and Community Services is notified that an individual is in receipt of the above noted services.

The 65Plus Plan

• Eligible to residents who are ≥ 65 years and receive Old Age Security Benefits and Guaranteed Income Supplement.

The Access Plan

• Eligible if low income; namely:
  • Families with children, including single parents, with net annual incomes of ≤$42,870
  • Couples without children with net annual incomes of ≤ $30,009
  • Single individuals with net annual incomes of ≤ $27,151

The Assurance Plan.

• Provides prescription drug coverage where eligible

drug costs exceed:

• 5% of net income for those who earn below $40,000
• 7.5% of net income for those who earn from $40,000 to under $75,000
• 10% of net income for those who earn from $75,000 to under $150,000

For the Access and Assurance Plan, co-payment is based on income and drug costs and is a percentage of prescription costs.

• Nunavut Health Care Plan, Extended Health Benefits [EHB]
• Non-insured Health Benefits [NIHB] Federal Program
• Federal Public Drug Benefit Programs

A] The Nunavut Health Care Plan is managed by Nunavut Health

Insurance Programs Office [in Rankin Inlet].
Use private coverage first. ARV is then covered under the Extended
Health Benefits Plan
Available to non-indigenous residents of Nunavut with a valid Nunavut Health Care Card and who are:

• a non-beneficiary [non-indigenous] 65 years or older
• a non-beneficiary [non-indigenous] Nunavut resident with a

chronic disease or illness as per defined list of diseases [this includes HIV].

• any Nunavut resident who has used up or does not have other

health care insurance options

Note that the EHB Formulary is the same as the NIHB Formulary. EHB will pay the full cost of approved prescriptions drugs listed in the NIHB formulary.

B] Non-Insured Health Benefits [NIHB] - A federal program, for those

that qualify. NIHB drug and pharmacy benefits
Must be a resident of Canada and one of:

• First nations person who is registered under the Indian Act

[commonly referred to as a "Status Indian"]

• Inuk recognized by an Inuit land claim organization
• A child <2 years whose parent is a NIHB-eligible client

Covers the full cost of ARVs listed in the NIHB formulary.
No deductible or co-payment
If client does have to pay out-of-pocket, there is a reimbursement process
Both Nunavut and Northwest Territories use the NIHB formulary

• Extended Health Benefits [EHB] - Specified Disease Conditions Program
• Non-Insured Health Benefits [NIHB] Federal Program
• Federal Public Drug Benefit Programs

A. The Government of Northwest Territories [GNWT] sponsors the Extended Health Benefits Program [EHB]. Private insurance must be used first [not eligible for EHB if client has other drug coverage].

Eligible if a permanent resident of Northwest Territories [NWT] and

• Non-indigenous
• Have a valid NWT Health Care Card
• Must be under the care of a MD/NP for an eligible disease [HIV is included]

There is an EHB application form for those <60 years and a form for those ≥ 60 years

• The Alberta Blue Cross administers the prescription drug benefits on behalf of the GNWT.
• No deductible or co-payment based on age or income
• Prescription Drugs: 100% coverage of eligible drugs [uses same formulary as NIHB]
• If a specific medication is not on the list, can submit it to the Alberta Blue cross for authorization.

B. Non-Insured Health Benefits [NIHB] - A federal program, for those that qualify. NIHB drug and pharmacy benefits

• Must be a resident of Canada and one of:
  • First nations person who is registered under the Indian Act
  • Inuk recognized by an Inuit land claim organization
  • A child <2 years whose parent is a NIHB-eligible client
• Covers the full cost of ARVs listed in the NIHB formulary.
• No deductible or co-payment
• If client does have to pay out-of-pocket, there is a reimbursement process
• Both Nunavut and Northwest Territories use the NIHB formulary

• Yukon Health Care Insurance Plan
• Federal Public Drug Benefit Programs

1. Chronic Disease and Disability Benefits Program

• HIV/AIDS is on the list of eligible diseases
• Must be <65 years.
• Annual deductible of $250; Deductible may be waved based on income.
• Doctor or community nurse must apply to program for client.

2. Pharmacare

• Must be ≥65 year [or > 60 years and married to a living Yukon resident at least 65 years of age].
• No deductible or dispensing fee; Will pay full cost of eligible drugs [see Formulary].
• Must have Pharmacare card at time of medication purchase [or else will need to pay out-of-pocket, then apply for reimbursement].

3. Children's Drug & Optical Program [CDOP]

• Assists low-income families with the cost of prescription drugs for children <19 years of age.
• No deductible
• Doctor or community nurse must apply to program for client