Ontario Drug Benefit billing reference
All ODB plans except Trillium are submitted as first payer. For Trillium with private insurance, the private-plan payment and eligible household-paid amount must be handled separately until the quarterly deductible is recorded as met.
Trillium: private insurance, receipts and quarterly limits
Carrier / Plan ID for ML
Enter the matching Carrier ID / Plan Code when using ML after an eligibility rejection, with valid proof retained.
Newborn: Carrier J and Adjudication Code ML
Use the baby's own Ontario health number or the detachable Ontario Health Coverage Infant Registration Form as proof. Confirm no private coverage and include Special Service Code U on every OHIP+ claim. If the normal eligibility lookup rejects, use Carrier J and Adjudication Code ML to establish OHIP+ for that date of service. If the baby's number is unavailable, contact the ODB help desk; do not substitute the parent's number.
OHIP+: U versus ML
U = no-private-insurance attestation. Enter U in the Special Service Code field on every OHIP+ claim after confirming no private plan with the patient or parent/guardian/agent.
ML = eligibility override. For a verified OHIP+ patient rejected with C2, C3, C8 or CJ, use Carrier J and Adjudication Code ML, with U still included. ML establishes eligibility for the date of service only; it is not required on every claim.
PM or ZR: reconfirm private-plan status. No private plan: resubmit with U, not an ML override for these responses. Private plan: do not use U; bill private insurance. For a Trillium household, submit eligible out-of-pocket receipts to TDP. Carrier S is not the OHIP+ carrier.
MK: Carrier ID is also required for a permitted one-day emergency override. MK is not available for H, J or a rejected 08 Home Care number.
Social assistance verification: SAV online or 1-888-284-3928.
Senior co-pay
Receipts from before applying
Yes, eligible earlier receipts can be reimbursed after approval. For a newly eligible senior, coverage starts the first day of the month after turning 65, not before. For an older first-time applicant, it generally starts August 1 of the eligible program year or the OHIP start date, whichever is later.
Prior program year: apply by September 30 after that year ends and submit receipts by October 31. An older senior applying August 1 to September 30 with prior-year receipts can be enrolled for that prior year. Reimbursement is limited to eligible costs from the confirmed coverage period, less the applicable co-payment.
Keep official pharmacy prescription receipts, not till or credit-card receipts. The current guide gives no fixed processing time; call 1-888-405-0405 for status.
What an approved senior pays
An approved Seniors Co-Payment Program member pays up to $2 for each eligible prescription and has no annual ODB deductible.
What the application asks for
Have the applicant's and spouse's Ontario health card and SIN details ready. Both people normally sign the application and consent to an income check with the Canada Revenue Agency.
Tax forms are not automatically required. If CRA verifies the income, no separate income documents are needed. A person without a SIN or recent tax return can still apply, but must provide another accepted proof of income.
- Fastest: complete the online application. Nothing has to be mailed after an online submission.
- Need a paper form mailed: call 1-888-405-0405. In Toronto, call 416-503-4586.
- Timing: a senior can apply up to three months before turning 65. The current income limits apply from August 1, 2026 through July 31, 2027.
Dispensing fees
Dispensing fees - limits and frequent-dispensing exceptions
5 fees per 365 days: listed chronic-use drugs, such as metformin, atorvastatin and ramipril. The period starts with the first claim.
2 fees per 28 days: the general cap, including levothyroxine and regularly scheduled fluticasone inhalers. Chronic-use drugs remain subject to this cap too. Product, setting and dispensing circumstances can create exceptions.
UN + a frequent-dispensing form (FDF): for response 87, a complex regimen with a safety risk or physical, cognitive or sensory impairment may qualify. Keep the written assessment, signed patient/agent agreement and written prescriber notification; renew every 365 days. A form or a prescription for weekly dispensing alone is not enough.
Other chronic-use exceptions include extemporaneous preparations and residents of designated Other Homes. Exemption from 5/year does not automatically exempt 2/28 days.
Exempted List No. 1: narcotics/controlled drugs, psychiatric medicines and facilitated-access palliative-care drugs. Examples include morphine, sertraline and quetiapine. Reduced quantities require a documented safety, abuse or diversion concern, written prescriber notification and ongoing reassessment.
Exempted List No. 2: applies when supplied in the Maximum Quantity defined by ODB. It also includes short-course or variable-use medicines, such as antibiotics and prednisone during tapering. It is a different list, not an extension of List No. 1.
Response 88: no intervention is listed for the 28-day cap. Check the applicable exemption rather than applying UN solely because an FDF is on file.
Fee rules and documentation · Chronic-use drug list · Exempted List No. 1 · Exempted List No. 2 · 87 / UN and 88 response table
Vacation Supply
Vacation supply - once per 365 days
One vacation supply per 365 days. August 1 does not reset eligibility. A July vacation claim does not permit another in August just because a new program year began.
For travel outside Ontario for more than 100 days:
- 30 days or more on hand: up to 100 days' supply
- Less than 30 days on hand: up to 200 days' supply
Keep a signed, dated travel letter with travel dates, or qualifying travel insurance. Use MV when submitting two 100-day claims on the same day.
Trillium: additional vacation supplies can be billed in quarters 1 and 2 (August 1 to January 31), not quarters 3 and 4 (February 1 to July 31). These are vacation rules, separate from ordinary days-supply limits.
Ontario Works / ODSP: absence beyond 7 days / 30 days respectively requires prior approval from the patient's caseworker.
Vacation supply form · Ontario vacation limits · Vacation billing and Trillium rules
Selected ODB responses
PM: OHIP+ no-private-insurance attestation missing
The claim is missing Special Service Code U, which confirms that an OHIP+ patient has no private drug plan.
Confirm private-plan status with the patient or parent/guardian/agent. No private plan: resubmit with U in the Special Service Code field. Private plan: do not use U; bill the private insurer. If enrolled in Trillium, submit insurer payment details and eligible out-of-pocket receipts to TDP. PM is not an ML eligibility override.
ZR: Submit receipt to TDP or attest to no private insurance
A claim for a Trillium-enrolled patient aged 24 or younger is missing confirmation of no private plan.
Reconfirm private-plan status. No private plan: resubmit as OHIP+ with U in the Special Service Code field. Private plan: do not use U; bill the private insurer and submit insurer payment details plus eligible out-of-pocket receipts to Trillium. ZR does not itself require ML.
ME: Possible drug/drug interaction
ODB severity levels 1 and 2 reject the claim; level 3 is an informational warning on a paid claim. Assess the interaction and its severity before dispensing.
Review the interaction. If dispensing remains appropriate, counsel the patient and resubmit the rejected claim with UG (patient cautioned; prescription filled as written). Document the assessment and counselling. If a different action is taken, use its matching intervention code.
87: Chronic-use dispensing fee - 5 fees per 365 days
The chronic-use fee limit has been reached, for example for metformin, atorvastatin or ramipril.
UN can be used when a documented chronic-use exception applies. For a frequent-dispensing assessment, record the safety risk from a complex regimen or impairment, obtain signed patient/agent agreement, notify the prescriber in writing and renew annually. The separate 2-fees-per-28-days rule still applies unless also exempt.
88: Zero dispensing fee - 2 fees per 28 days
The 28-day dispensing-fee limit has been reached. This is separate from response 87 (five fees per 365 days).
Check whether an Exempted List or designated-residence exception applies. UN is not listed for response 88; a frequent-dispensing form alone does not remove this cap. See the dispensing-fee policy for the qualifying conditions.
Worked examples
Newborn with an eligibility rejection
A newborn has their own Ontario health number and no private drug plan, but the claim returns C8. Retain the infant registration proof, submit Carrier J and Adjudication Code ML for that service date, and include Special Service Code U. The parent's health number is not a substitute.
Missing OHIP+ attestation, not missing eligibility
A youth in a Trillium household returns PM. Reconfirm whether that patient has private coverage. If not, resubmit with U. The family's Trillium enrolment and PM alone are not reasons to add ML or Carrier S.
Weekly dispensing after a fee limit
For response 87, an eligible, documented frequent-dispensing arrangement can support UN; retain the required clinical rationale and agreement. Response 88 is a different limit and does not list an intervention code. A signed form does not turn UN into a universal fee override.
See the source links in the carrier-ID, dispensing-fee and response sections above for each condition.
Sources and scope
Independent pharmacy-facing reference, not an Ontario government service. The linked Ontario manuals and program guides control eligibility and payment. Source links appear beside the applicable rules. Confirm the current claim response and retain the required documentation.
Ontario Drug Programs Reference Manual (revision 17, August 3, 2026); program guides and dispensing-fee notices linked above.
Source-verification policy | Report a correction. Do not send patient or claim identifiers.