Kitchener, Waterloo & Cambridge Area

29 Young Street East
Waterloo, Ontario N2J 2L4 (Google Map)
Telephone: 519-603-0223
Fax: 519-888-6422
Email: info@sanguen.com

Wellington, Dufferin & Guelph Area

176 Wyndham Street North
Guelph, Ontario N1H 8N9 (Google Map)
Telephone: 877-351-9857
Fax: 519-888-6422
Email: info@sanguen.com

Hepatitis C Treatment Coverage in Ontario

Hepatitis C Information

(adapted from the CATIE website:
www.hepcinfo.ca)

You may have heard that hepatitis C medications are very expensive. If you have questions about the cost of treatment, about whether you can afford treatment, or about whether you’re eligible for assistance, please talk to us. We are often able to help patients to obtain coverage.

The information below may be helpful if you are in Ontario.

At Sanguen, we are familiar with all of the programs listed below and can help you to understand your options, what’s available to you, how to apply for assistance, and/or how to contact your insurance company.

 

Private Health Insurance

Some health insurance policies offered through private insurance companies include (partial) coverage for prescription drugs. These programs often have their own deductible, or co-pay fee, and may have yearly maximums for prescription drugs. Often the patient needs to apply to the Trillium Drug Program to cover the remainder of the cost.

Please be aware that applying for these programs takes time.

It can take anywhere up to 2 months.

 

Prescription Drug Programs

General information on drug coverage and benefit programs offered by the provincial, territorial and federal governments can be found here.

 

Coverage for Hepatitis C Medications

The Ontario Drug Benefit Program (ODB) and the Trillium Drug Program (TDP) are the two main programs that assist Ontario residents with covering the costs of expensive prescription drugs and may be able to help cover the high cost of hepatitis C treatment medications.

 

What is the Trillium Drug Program?

The TDP provides drug benefits to Ontarians who have high drug costs in relation to their household income. Residents who do not qualify for any of the other programs can apply for the TDP. An annual deductible and co-payments (based on household income) apply to all recipients of the TDP, which is paid in four installments throughout the year.

 

What is the Ontario Drug Benefit Program?

Individuals who receive social assistance, either through Ontario Works (OW) or the Ontario Disability Support Program (ODSP), may be eligible for prescription drug coverage through the ODB.

 

How do you apply for coverage of Hep C meds?

In Ontario, the following hepatitis C medications are eligible for coverage under the Exceptional Access Program (EAP):

  • peg-interferon and ribavirin
  • boceprevir (taken in combination with peg-interferon and ribavirin)
  • simeprevir (taken in combination with peg-interferon and ribavirin)
  • telaprevir (taken in combination with peg-interferon and ribavirin)

These hepatitis C medications must be approved for coverage by the EAP before they will be paid for by one of the publicly funded drug programs. People can ask their hepatitis C specialist to submit a request form to the EAP for coverage of their hepatitis C medications. The request form will be reviewed against the clinical criteria for coverage, set out by the Committee to Evaluate Drugs (CED).

Some of the factors that are considered when approving funding for hepatitis C medications include:

  • a positive HCV RNA test
  • HCV genotype
  • elevated ALT levels or level of fibrosis
  • child-Pugh score or level of cirrhosis
  • whether or not an individual is treatment naïve
  • whether or not an individual is living with chronic hepatitis C
  • whether or not a person has been previously treated and what their response to treatment was
  • HIV status

The full criteria for funding of hepatitis C medications can be found in the Frequently Requested Drugs document. Funding criteria for epoetin is also included in the document.

The requesting physician will receive a letter from the EAP telling them whether or not coverage will be granted or if more information is required. If the request is approved, people will have their hepatitis C medications covered for a designated time period. A request to extend the period of coverage is usually necessary in order for people to have their medications covered for the duration of their treatment.

If people would like more information about drug programs in Ontario, they can call the Exceptional Access Program Branch (EAPB) of the ODB at 1-866-811-9893 or TTY at 1-800-387-5559.

 

What about coverage under the Non-Insured Health Benefits program?

Registered First Nations and recognized Inuit people may be able to access coverage for their hepatitis C medications through the Non-Insured Health Benefits (NIHB) program. People can contact NIHB by phone or mail at:

Non-Insured Health Benefits – Ontario Region
First Nations and Inuit Health
Health Canada
1547 Merivale Road, 3rd floor
Postal Locator 6103A
Nepean, Ontario
K1A 0L3
Toll-free: 1-800-640-0642

Costs and Coverage for Treatment in Canada

Some programs can be accessed by all Canadians. Examples include:

Private health insurance

Some health insurance policies offered through private insurance companies include coverage for prescription drugs. These programs often have their own deductible, or co-pay fee, and may have yearly maximums for prescription drugs.

Programs offered by pharmaceutical companies

The pharmaceutical companies that make Hep C medications have programs to help people complete treatment. Merck has the Merck Care program for people taking peg-interferon alpha-2b (known as Pegetron). Hoffman-La Roche has the Pegassist program for people taking peg-interferon alpha-2a (known as Pegasys). Vertex has the Incivek Care program for people taking telaprevir (known as Incivek). Gilead Sciences has the Momentum Support program for people taking sofosbuvir (known as Sovaldi).

These programs have phone support for people on treatment, and part of this support is helping people to access the funding necessary to cover treatment costs. These programs can inform patients about local, provincial, and federal government programs for accessing treatment and can help the patient find out ways to maximize any public funding or private medical insurance (including the appeals process, if the patient also has a supportive doctor). If a person is eligible, some programs can help cover the insurance company co-pay fee, provincial or territorial plan’s deductible, and a number of other expenses, depending on a person’s specific situation.

For more information, contact:

Pegassist Program
1-877-PEGASYS (1-877-734-2797)

Merck Care Program
1-866-872-5773

Incivek Care Program
1-877-574-4298

Momentum Support Program
1-855-447-7977

People who contracted hepatitis C from a blood transfusion between 1986 and 1990 may be eligible to have hepatitis C treatment expenses covered by the Hepatitis C January 1, 1986 – July 1, 1990 Class Actions Settlement. To learn more about these programs, see Compensation.