Since having written another article about Ozempic in 2023, Ozempic continues to be a topic of both curiosity and concern. The surge in demand for Ozempic has led to intermittent nation-wide shortages. Having become such a hard to obtain resource, an important question stands: Does OHIP cover Ozempic? In this article, we’ll be answering just that. 

What is Ozempic?

Ozempic is a prescription medication used to control blood sugar levels in people with type 2 diabetes. It is typically prescribed in a once-a-week, subcutaneous (under the skin) injection, using a pre-filled pen.

Ozempic belongs to a class of drugs known as glucagon-like peptide-1 (GLP-1) receptor agonists. GLP-1 is a hormone that plays a crucial role in sugar metabolism. It works by mimicking the effects of the natural hormone in the body. Traditionally known for type 2 diabetes management, it has also been less commonly used for cardiovascular issues. That being said, the medication has taken on a new identity in recent years, having spiked in popularity as a weight loss medication. 

Coverage of Prescription Medications And Ozempic Under OHIP

The Ontario Health Insurance Plan (OHIP) does not directly cover prescription medications, including Ozempic. In Ontario, coverage for prescription drugs is managed specifically under the Ontario Drug Benefit (ODB) program. Unfortunately, the ODB program is limited in who is qualified for coverage. 

You might be covered under the ODB program if you meet certain criteria: 

• Age Factor: People aged 65 and over are covered under this program.
• Income-Based Programs: Those receiving benefits from Ontario Works or the Ontario Disability Support Program (ODSP) also qualify.
• Special Circumstances: Residents of long-term care homes or those enrolled in special programs like the Trillium Drug Program, which is designed for people who have high prescription medication costs relative to their income, might also have coverage.
• OHIP+: Covers anyone 24 years or younger who is not under a private plan. 

Nevertheless, not all prescription medications are covered under the ODB program. The Ontario Drug Benefit (ODB) formulary lists all 5,000+ covered medications. Additionally, there is no guarantee that it will fully cover all costs associated with eligible medications. If not, the ODB will cover the costs partially. 

Does OHIP Cover Ozempic Specifically?

Depending on your need for the medication, you may be covered for Ozempic under the Ontario Drug Benefit Program (ODB). In February 2024, Ozempic became a limited use medication, which means it can only be covered under specific clinical circumstances. 

To meet the Limited Use (LU) criteria for Ozempic, you must be an adult patient with type 2 diabetes. You must have not attained adequate glycemic control with the maximum dose of metformin. You will also be eligible if metformin is not considered an appropriate treatment for your diabetes. 

The Ontario Drug Benefit (ODB) formulary changes consistently throughout the year. You should continue to check the eligibility of certain prescription drugs to stay up-to-date and aware of whether your medications are covered. If a medication is not included in the ODB formulary, patients might have to pay out-of-pocket or seek coverage through private insurance plans.

Alternatives and Supplemental Insurance Options

When a specific medication like Ozempic is not covered under OHIP or the Ontario Drug Benefit (ODB) program, individuals may need to explore alternative insurance options to manage costs.

Employee benefits can sometimes include additional prescription medication not listed in the ODB. It’s crucial to review your health insurance policy in detail or speak with your HR department or insurance provider to understand what medications are covered. You should also check for any associated co-pays or deductibles if you haven’t already done so. 

Purchasing private health insurance may also be an option for those who do not qualify for the ODB or those who do not have employee-sponsored benefits. Insurers often offer an insurance package that covers more extensive drug medications. Comparing different plans and insurers will provide insights into cost-effectiveness and coverage levels suitable for your medical needs.

Keep in mind that your ability to receive coverage for Ozempic may still depend on your reason for usage. For more specific information on coverage for Ozempic, you can check out our article: Is Ozempic Covered by Manulife?

Conclusion: Understanding Your Insurance Coverage

Understanding the available options can greatly alleviate the challenge of accessing particular prescription drugs. While OHIP does not directly cover prescription medications, programs like the Ontario Drug Benefit (ODB) and OHIP+ play crucial roles in providing necessary medications to specific groups. It’s not always straightforward what prescription drugs OHIP covers, especially when it comes to limited use drugs like Ozempic. This article provides valuable resources to fully assess your coverage options.