Ontario Regulation 97/26 amends Ontario Regulation 201/96 under the Ontario Drug Benefit Act, modernizing co-payment rules for eligible recipients of listed drug products and revising income calculation rules used to determine benefit eligibility and financial relief under the Ontario Drug Benefit program. The regulation introduces a defined term, “section 20.2 maximum co-payment,” and makes consequential amendments throughout the framework governing pharmacy charges, deductible calculations, and income-based assistance under the Ontario Drug Benefit program. The amendments also align administrative reporting and pharmacy billing practices with updated federal tax and benefit definitions used in income testing across the program framework.

The regulation significantly revises the definition of “annual net income” used across O. Reg. 201/96. Net income is based on the amount on the Notice of Assessment under the Income Tax Act, adjusted to exclude the Universal Child Care Benefit and withdrawals from Registered Disability Savings Plans. It also specifies that the Canada Disability Benefit is excluded from income for all program calculations.

A major amendment restructures section 20.2 governing co-payments for eligible persons receiving listed drugs. It introduces a tiered system linking payments to fiscal periods and allowable drug costs, with a $100 deductible threshold. Until reached, patients pay standard Ontario Drug Benefit amounts, with minor offsets based on pharmacy type and dispensing fees.

After allowable drug costs approach or exceed the deductible, a transitional rule ensures co-payments do not exceed the remaining balance to reach it. Once met, reduced co-payments apply and vary by dispensing setting, including hospitals, physician dispensing locations, and other pharmacies, with lower caps than pre-deductible amounts. The deductible is also prorated for mid-year eligibility.

Section 20.3 creates a relief mechanism from standard co-payment rules for eligible persons meeting income-based criteria. Relief requires application and depends on income falling below thresholds, with categories for individuals, couples, and separated spouses.

Applicants may elect alternative taxation years in specified circumstances, and spouses’ income is assessed jointly where applicable. The Ministry may reassess applications as new filings when circumstances change, ensuring ongoing accuracy of eligibility determinations.

Section 20.5 establishes income thresholds and indexing mechanisms. For fiscal periods beginning in 2024 and 2025, thresholds are set at $25,000 for individuals and $41,500 for combined household income. Beginning in 2026, these thresholds are automatically adjusted using the Ontario Consumer Price Index, with safeguards preventing decreases and requiring publication of updated values. The Ministry is required to publish updated thresholds annually.

Ontario (97/2026) April 22, 2026
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