Capitation in Ontario

Capitation was implemented in response to policy changes by the Ontario Ministry of Health and Health Canada to limit dispensing fees for multiple fills of prescriptions covered by Ontario Drug Benefit (ODB) and Non-Insured Health Benefits (NIHB) programs. To learn more, watch the video below:

What is Capitation?

Capitation is a reimbursement method whereby providers receive fixed payments for health services provided to plan members. This means that dispensing fees paid to the Pharmacy are limited to a specified number of prescriptions in a specified time frame.

Refer to the table below for details of and exemptions to the policies.

Who does it affect?

It affects patients who receive monthly, multiple fills of a medication using compliance packaging, such as 7-day supply, 14-day supply, blister packs, Blister, and Dosett.

Capitation affects Retail ODB Patients:

NIHB Policy	Exemptions
Pharmacies are entitled to a maximum of two (2) dispensing fees per month, per medication.	Subsequent fills during the month must be submitted with $0.00 fee. Exemptions Drugs on the Exempted Medications list, per the Ontario Ministry of Health and Long-Term Care, including Homes for Special Care. Refer to ODB Exemptions & Exceptions section for further details.
Excludes drugs on Exempted Medications list.
Subsequent fills during the month must be submitted with $0.00 fee.	Patients in registered long-term care facilities, including Homes for Special Care.

Capitation affects Retail NIHB Patients:

NIHB Policy	Exemptions
Pharmacies are entitled to a maximum of one (1) dispensing fee per 28 days, per medication.	Refills for intermittent treatment of a chronic disorder (e.g. dosage patients).
Excludes drugs on Exempted Medications list.	Methadone
Subsequent fills during the 28-day period must be submitted with $0.00 fee.	High-risk drugs where safety, risk of diversion, and compliance are a concern.
	Other drugs as defined by the policy.