• Overall, private plans may offer greater coverage of innovative medicines, and sometimes in a shorter time frame than public ones.
• Private plans offered by employers are part of a compensation package and serve as a retention and productivity objective, much like a performance bonus.
• Public plans are designed to cover populations which are outside of the workforce, such as seniors, disabled and unemployed.

• Every insurer has a formulary, a list of medications that are covered by the plan.
• In general, private plans cover more medications than public ones.
• Within your private insurance benefit plan, you can search the company’s formulary to see if your medication(s) is/are covered by searching the DIN of the prescription. Most companies have an online tool to allow people to consult the formulary.
• If the medication you are looking for is covered by the insurances company’s formulary and you are denied access, it is likely because your employer has not included that medication or class of medication on the plan they purchased.
• If you are still unsure if your drug is covered by your plan, you can call the insurance company or the pharmacist to find out. It is important to have your policy number of group health benefits number on hand. If you cannot find these numbers, contact your human resources department or your employer. It may also be helpful to know the DIN before contacting the insurance company.

• Some health plans require members to take additional steps before medications are covered. Programs like prior authorization, step therapy, managed formularies and case management may involve additional steps for physicians and patients.
• Prior authorization: requires your physician to obtain approval from your health insurance plan to prescribe a medication. The physician usually has to explain to the insurer why the patient needs this medication. Often, the insurer wants the doctor to try a cheaper alternative first.
• Step therapy: also known as fail first, requires the patient to try one or more medications (specified by the insurance company) to treat a condition. These medications are often lower cost or generic. The patient must fail on this therapy in order to be promoted to another medication that is usually more costly.
• Managed formularies: a tiered formulary that encourages the use of low-cost alternative for select classes. This exists for brand name drugs for which more cost-effective and safe alternatives exist. Plan members still have access to the brand-name drug, but it is reimbursed at a lower level.
• Case management: designed to provide for a patient’s needs while controlling costs. Insurance companies may assign a case manager to monitor a particular patient.

• Confirm if the medication you are going to be prescribed is on the formulary list. If it is not, you will need do self-advocate (see advocacy section below).
• Arrange for paperwork to be filled out in a timely manner or in advance if possible.
• Communicate any restrictions to your physician.
• You may need to follow up with your physician to make sure the paperwork has been completed.

• There are supplemental fees added to the cost of the medication. There are markups added to compensate the wholesaler and the pharmacy, as well as pharmacy dispensing fees. The markup is usually a percentage of the cost of the drug, so it varies based on the product. The dispensing fee is normally a fixed amount charged by the pharmacy, and it may even be greater than the cost of the product in the case of low-cost medications. Fees and markups vary between pharmacies and even within pharmacies based on the type of insurance program. These costs can also vary based on where the medication is picked up. Some employers may have specific arrangements with insurance providers to negotiate lower fees and markups with pharmacy chains. Other factors that may affect cost include the duration of the treatment, the frequency of dispensing, the potential for non-adherence and the cost of alternatives being replaced. For example, if a medication used for a chronic condition is dispensed more frequently but in smaller quantities, it could have a higher cost due to the more frequent refills.

• Find out from the insurer how the cost of medications are reimbursed.
• Reimbursement may be at the time of purchase or afterwards. You may or may not be required to submit a claim:
• At the time of purchase: you only pay your contribution of the cost of the medication at the pharmacy. The insurer then pays its portion to the pharmacist.
  • Nowadays, this is the most common way to get reimbursed.
  • Most insurance companies issue an insurance card that you must present to the pharmacist in order for the insurances part to be billed directly to them.
• After purchase, no claim necessary: The full cost of the medication is paid at the pharmacy. Next, the pharmacist submits a claim to your insurer on your behalf and then you receive the reimbursement.
• After purchase, claim required: The full cost of the medication is paid to the pharmacy. Next, you submit a claim to your insurer, attaching the invoice or receipt for the medications purchased. You then receive reimbursement.

• This can happen when you and your spouse (or parents) both have plans, and you have coverage by both. It is important to coordinate your plans. Claims generally are submitted in order of who’s birthday comes first. For example, someone with a birthday in January is the first plan to be submitted to and then the person whose birthday is in July will pick up the unpaid portion that the first plan didn’t cover.

• It is possible to buy individual or family health plans. For more details, consult an insurance broker. Examples of companies that offer health insurance plans include Canadian Association for Retired Persons and the Canadian Automobile Association. Group coverage may be advantageous because the cost can be shared over many people, resulting in lower premiums for each individual.

• Sunlife https://www.sunlife.ca/en/
• Manulife https://www.manulife.ca/personal.html
• Blue Cross http://www.bluecross.ca/en/index.html
• CAA https://www.caalifeandhealth.ca/caa/
• Costco https://www.memberhealthplan.com/costco/health_dental.jsp?lang=E&MKT=A26
• Great West Life https://www.greatwestlife.com/you-and-your-family.html
• Desjardins https://www.desjardinslifeinsurance.com/en
• A comparison of the major companies can be found here: https://www.howtosavemoney.ca/health-insurance-canada

• Eligibility for public plans is very diverse and changes between provinces. Some provinces and territories focus mainly on seniors and those with low incomes while others have universal plans for all eligible residents.
• Studies show that 11.3% of the Canadian population is eligible for an insurance plan but is not enrolled. Reasons for this vary from lack of need to lack of information.

• Public plans use health technology assessment (HTA) tools to decide which drugs are covered. HTAs evaluate the clinical- and/or cost-effectiveness of a drug. They may also evaluate the ethical, legal and social implication of the product on patient health and the health care system.
• Public drug plans have values that differ from private. The private sector focuses on productivity, which is different from what HTAs focus on.
• Quebec’s HTA (INESSS) take a more holistic and societal approach to the patient experience. The Canadian Agency for Drugs and Technology in Health focuses on whether or not a drug is going to reduce hospital and physician visits. The pan-Canadian Pharmaceutical Alliance is more focused on overall budget and compares a drug’s cost to the cost of other therapies.

• Manitoba Pharmacare is available to all residents who have a valid provincial health card. Residents must be eligible for Manitoba Health, Seniors and Active Living Coverage and their prescriptions must not be covered by other provincial or federal programs.

Enrollment

• Application is required via mail or fax. More information can be found here
• Currently, 62% of Manitobans are enrolled in a public health plan.

Costs

• Enrollment in PharmaCare is free, but there is a deductible. Each year, Manitobans are required to pay a portion of the costs of eligible prescription drugs. This annual deductible is based on the adjusted family income. You can calculate the estimated deductible here

Which Program Pays for Medications First?

• If eligible, drugs are first paid by the public program. The remaining amount may be claimed with private insurers.

More information can be found on Manitoba’s website

• The New Brunswick Drug Plan provides coverage for uninsured residents who have an active Medicare Card and meet one of the following:
  • Do not have drug coverage through a private plan or other government program
  • Have existing drug coverage with a private plan but have reached their annual or lifetime maximum or have been prescribed a drug not listed on the private plan’s formulary.
• The New Brunswick Prescription Drug Program (NBPDP) provides drug benefits for eligible groups including seniors, cystic fibrosis patients, organ transplant patients and many other. The complete list can be found here
• The New Brunswick Drugs for Rare Disease Plan provides assistance for the cost of certain drugs for rare diseases. Information regarding the diseases and how to apply can be found here

Enrollment

• The application for the New Brunswick Drug Plan can be found here
• Applications for the NBPDP can be found under each respective beneficiary group here.
• For the Rare Disease Plan, please consult their website.
• 17% of the population is enrolled in a public plan, while 43.6% is eligible.

Costs

• The New Brunswick Drug Plan has both premiums and copayments based on income. Details can be found here
• Some NBPDP groups have registration fees and copayments. Please consult the individual webpages for more details.

Which Program Pays for Medications First?

• Eligible prescriptions must be claimed with the private plan first. The public plan will reimburse the remaining amount if the drug is eligible.

Complete information can be found on New Brunswick’s website.

• The Newfoundland and Labrador Prescription Drug Program (NLPDP) has 5 main plans for their residents:
  • The Foundation Plan: for those in need of greatest support. This includes recipients of income support benefits through the Department of Advanced Education and Skills, and certain individuals receiving services through the regional health authorities, including children in the care of Child, Youth and Family Services, and individuals in supervised care.
  • The 65Plus Plan: for 65+ who receive Old Age Security Benefits and Guaranteed Income Supplements.
  • The Access Plan: For low income families and individuals.
  • The Assurance Plan: for families/individuals whose drug costs are excessive. Eligibility varies based on income and drug costs.
  • The Select Needs Plan: to cover disease specific medication for residents with cystic fibrosis and growth hormone deficiency.

Enrollment

• Applications are required for the Access Plan and Assurance plan.
• About 69.1% of residents are enrolled in a public plan.

Costs

• Costs vary according to the program.

Which Program Pays for Medications First?

• If eligible, drugs are first paid by the public program. The remaining amount may be claimed with private insurers.

For more information, please consult the NLPDP’s webpage

• The Seniors’ Pharmacare Program is for residents who are 65 years, have a valid Nova Scotia Health Card and do not have prescription drug coverage under any other plan and program.
• The Family Pharmacare Program is for residents of Nova Scotia with a valid health card as long as they agree to family income verification through the CRA and agree to provide family size information every year.
• There are additional programs for cancer patients, palliative care and department of Community Services. Information can be found here

Enrollment

• Registration is required for the family plan. More information can be found here
• Program information and enrolment packages regarding the seniors’ program are mailed to residents with a Valid Nova Scotia Health Card approximately 3 months before their 65th birthday.
• For the other programs, please consult their website.

Costs

• There is no enrollment fee for the Family PharmaCare program, but beneficiaries are required to pay a part of the cost of certain prescription drugs. The cost of the deductible and copayment amounts can be found here.
• The seniors’ program has a premium and copayments with annual amounts. The province covers the rest of the costs. The amounts can be calculated here.
• For the other programs, please consult their website

Which Program Pays for Medications First?

• Eligible prescriptions must be claimed with the private plan first. The public plan will reimburse the remaining amount if the drug is eligible.

For complete information, refer to the Nova Scotia website

• Ontario offers the Ontario Drug Benefit Program (ODB). You are eligible for ODB if you are:
  • 65 years or older
  • Living in a long-term care home, home for special care or community home for opportunity
  • 24 years or younger and not covered by a private insurance plan
  • Receiving professional home and community care services
  • Receiving benefits from Ontario Works or Ontario Disability Support Program
  • Enrolled in the Trillium Drug program

Enrollment

• Seniors aged 65 years and older will be automatically enrolled.
• Trillium Drug Program Application can be found here
• 40.2% of the population is eligible for public programs, 24.1% is enrolled.

Which Program Pays for Medications First?

• Eligible prescriptions must be claimed with the private plan first. The public plan will reimburse the remaining amount if the drug is eligible.

Costs

• Costs depend on the elig:ibility category you fall into. Please consult the “what you pay section” https://www.ontario.ca/page/get-coverage-prescription-drugs#section-1

For more information, please see Ontario’s website

• There are many drug programs available including the Generic Drug Program, Family Health Benefit Drug Program and the High Cost Drug Program. The complete list can be found here
• In order to be eligible, you must be a permanent resident of PEI, have a valid PEI Health Card, your medication must be listed on the PEI pharmacare formulary and you must qualify for one of the drug programs.

Enrollment:

• Enrollment for the Senior’s Drug Program is automatic at the age of 65.
• For other programs please refer to their respective webpage
• It is estimated that 42.1% of Islanders are eligible for PEI Pharmacare and 30.3% are enrolled.

Costs

• Costs vary according to the plan.

Which Program Pays for Medications First?

• Eligible prescriptions must be claimed with the private plan first. The public plan will reimburse the remaining amount if the drug is eligible.

For complete information, please consult PEI’s website

• In Québec, it is required to be registered with a health insurance plan. For those without private insurance, the public plan is offered by the Régie de l’assurance maladie du Québec. More info can be found here
• In order to be eligible for the public plan, you must not be eligible for a private plan and be registered with the Régie.

Enrollment

• Residents must register with the Régie. You can do so here
• Seniors (65+) are automatically enrolled and may opt out if they have private coverage.
• Social assistance recipients are also automatically enrolled in the public plan.
• It is estimated that 43.6% of the population is enrolled in the public plan.

Costs

• There is an annual premium adjusted annually based on your situation and net family income. It is required to be paid even if you do not purchase prescription drugs. It is collected through your income tax return.
• There is a monthly deductible, co-insurance and maximum contribution. Details can be found here
• Details regarding those who are free of charge can be found here

Which Program Pays for Medications First?

• Due to the structure of the Régie, residents of Québec cannot be covered by both private and public programs.

For more information, please consult Québec’s website

• Saskatchewan has many programs including the Children’s Drug Plan, Drug Cost Assistance, Emergency Assistance for Prescription Drugs and the Saskatchewan Drug Plan. All the plans can be found here
• Eligibility depends on the program but based on the criteria defined by the numerous plans, roughly the entire population is eligible for a program.
• In order to be eligible, residents must have valid Saskatchewan health coverage and must not be covered by federal programs such as Veterans Affairs.

Enrollment

• The need for application varies based on the program. Please consult the website for the program you qualify for.
• 54.5% of the population is enrolled in a public program.

Costs

• Deductibles and co-payments vary based on the program.

Which Program Pays for Medications First?

• If eligible, drugs are first paid by the public program. The remaining amount may be claimed with private insurers.

More information can be found here

• The government of the Northwest Territories (GNWT) sponsors the Métis Health Benefits program for registered Indigenous Métis residents. Information and application can be found here:
  • Applicants must have a valid NWT Health Care Card.
  • If the applicant has access to benefits under an employer or similar plan, and chooses not to use them, then they are not eligible for this program.
• The Extended Health Benefits for Seniors Program is for NWT residents who are over the age of 60, Métis or non-Indigenous and have a valid NWT Health Care Card. Applicants must not have foregone a private plan from their employer to be considered.
  • https://www.hss.gov.nt.ca/en/services/applying-extended-health-benefits-seniors-program
• Métis or non-Indigenous permanent residents of NWT with certain disease may apply for the Extended Health Benefits for Specified Disease Conditions Program.
  • Details and the list of diseases can be found here.

• There are 4 drug programs for the residents of Yukon:
  • Pharmacare: for seniors 65 years and older.
  • Chronic Disease Program: For those who have a chronic disease or a serious functional disability.
  • Children’s Drug and Optical Program: to assist low income families with the cost of prescription drugs and eye care for children under the age of 19.
  • Palliative
  • For information on each program: http://www.hss.gov.yk.ca/insuredservices.php

• The Non-Insured Health Benefit (NIHB) program provides eligible First Nations and Inuit clients with coverage for benefits that are not covered through social program, private insurance plans and provincial or territorial health insurance. Client identification must be showed in order for providers to bill the program.
• For more information: https://www.sac-isc.gc.ca/eng/1576790320164/1576790364553

• Even if you have insurance, there may be times when your claim is rejected.
  • Be sure to understand your rights under your policy (what you are eligible for).
  • Make sure the paperwork was accurate.
• If you believe you are entitled – appeal. Be persistent and don’t back down. Make phone calls and/or send emails to inquire to get more information about the rejection.
• Most insurers have an appeal process. Be sure your physician is providing the necessary supporting documentation (correct diagnosis, dosing etc). It’s not uncommon that a rejection is due to insufficient or inadvertent information.
• Most insurance companies have an ombudsman or complaints officer. It is their responsibility to help with complaints.
• If your situation continues to be unresolved, request a letter from your insurance company stating their final position and any supporting documentation.  There is a free, national services of the impartial OmbudService for Life and Health Insurance (OLHI) to help you with your claim.
• Keep a record of ALL your correspondence and medical information.
• Ensure your human resource department is aware and kept current of your situation.
  • The human resources department should be able to help you with your claim and often the employer can help to overturn the rejection or add your medication to the approved formulary list.

• Sometimes an employer has excluded medications from the approved list of medications for reimbursement in their plan.
• You may consider disclosing your condition to your HR manager.
  • Describe your condition and ask your employer either to update the drug plan to include your medication as part of the plan or to make an exception. They have the power to do this!
• If the medication or service is not covered, ask your health benefits manager (often the HR manager) why they decided to not to cover the drug. You might be able to apply for alternative coverage. Escalate your issues as appropriate until you receive a reasonable response.
• Ask if there is an opportunity to apply for interim coverage so you have access to the medication your physician has prescribed based on your medical history.
• It is in the best interests of a company to keep employees healthy and at work. Presenteeism, absenteeism and disability are costly.
• In detail, document all your communication and exchanges with your employer / plan sponsor and/or insurer.