What is the reimbursement status of neuropathic pain medications?
How do I apply for Section 16 coverage?
Your doctor must send an ICR (Section 16) form on your behalf, describing your neuropathic pain to the Ministry of Health and Long-Term Care Individual Clinical Review Unit. Medical experts will review your doctor's request and will advise him or her, within two to three weeks, whether coverage has been approved. Make sure your doctor knows that he or she must sign the letter and meet the clinical criteria.
You can click here to download the form for your physician to fill and send.
How will I know my Section 16 has been approved?
Check with your physician because the Ministry of Health and Long-Term Care Individual Clinical Review Unit will notify him or her about whether coverage has been approved for you. Most decisions are made within three weeks.
What can I do if my Section 16 is denied?
Your doctor can appeal the rejection by writing the Ministry of Health and Long-Term Care Individual Clinical Review Unit. Most rejections occur because the physician initially provided inadequate information. You may want to review the eligibility criteria outlined in bullet point 1 with your physician.
Alternatively, you can contact your local MPP for assistance or click here to Take Action to email your MPP.
When can I apply for reimbursement?
You will be eligible for reimbursement under Ontario's public drug plan once your Section 16 is approved.
Will my Section 16 need to be renewed periodically?
Yes. Section 16 coverage is given on a case-by-case basis for periods of time usually ranging from 1 to 5 years. Six weeks before the expiry of the approval, your physician must send a letter to the Ministry of Health and Long-Term Care Individual Clinical Review Unit requesting a Section 16 renewal. You should remind your physician to do this.
Where can I get help to pay for the drug?
Most employer sponsored private insurance drug plans cover the neuropathic pain medications.
People without private insurance plans need to request Section 16 coverage. Once their Section 16 request is approved, individuals can access either the Ontario Drug Benefits Plan or the Trillium Drug Program to help cover the cost of the drug.
Ontario Drug Benefits (ODB) Plan:
You are eligible for ODB benefits if you are:
Trillium Drug Program:
The Trillium Drug Program (TDP) is intended for Ontario residents who have a valid Ontario Health Card and who have high prescription drug costs in relation to their net household income.
People who are not 100% covered by a private or employer paid drug plan can apply to the Trillium Drug Program (TDP) to help pay for a large portion of the cost of the drug.
Trillium applications forms and guides are available from your local pharmacy, or by calling 1-800-575-5386, or on line.
Can I apply to Trillium if I have private drug coverage?
Yes. You can use the Trillium Drug Program (TDP) to help pay the difference between the cost of the drug and what your private benefits cover.
Do I have to pay a portion of the cost myself?
If you are eligible for ODB, you may have to pay $2 to $6 per prescription.
Under the Trillium program, you must pay a certain amount on prescription drugs (deductible) each quarter.