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Introduction to Public and Private Reimbursement of Medications and Services

Understanding how medications and services are reimbursed is complicated and differs between provinces and insurers/plans. The information in this section will help clarify the different ways medications are made accessible to you. 

Most Canadians (54%) have some form of private insurance – either through their employer or self-purchased. Approximately 36% rely on their province’s public drug formulary to pay for their prescription medication(s). Unfortunately, a portion (7%) of Canadians fall between the cracks and don’t have private insurance and don’t qualify for public coverage. 

Over the course of the past several years, there has been an increase in new treatment options for SpA patients. However, it’s important to understand that what may be approved and reimbursed for one condition may not be available for another. For example, a medication approved for Psoriatic Arthritis may not be available for Axial Spondyloarthritis and vice versa. It is also important to understand that what is paid for in one province may not be paid for in another province. This speaks a bit to how our health system isn’t perfect.

This section will help you understand and navigate the programs to determine what is covered under your provincial or territorial public reimbursement drug plan and your private insurance plan. Unfortunately, the plans do differ between provinces and insurers making the navigation more complicated.

The CSA is committed to advocating that Canadians have equal access to medications and services from coast to coast.

In this article:

Definitions

Definitions Relevant to Both Public and Private Reimbursement

  • Beneficiary: The individual who makes the claim and gets reimbursed.
  • Uninsured: Individuals who are not eligible for public drug coverage and who are not enrolled in a private drug insurance plan.
  • Premium: A fixed amount paid, usually monthly or annually, by a plan member in order to be eligible for drug insurance coverage under a given plan. It is typically paid regardless of whether drug expenses are incurred by the given member, and the amount is generally based on the claims experience in a private group plan or income-based in a public plan.
  • Deductible: The amount that a beneficiary must pay out of pocket either monthly or annually towards their prescriptions over a specific period before reimbursement coverage begins. After a deductible limit has been reached, the beneficiary becomes eligible to receive benefits. Deductibles vary between plans and some don’t have any.
  • Fixed co-payments/co-insurance: A fixed cost that a beneficiary may be required to pay per prescription (co-payment), or a system in which a beneficiary pays a percentage of the cost required to fill a prescription (co-insurance). These take place after deductible limits have been reached. Most plans require co-insurance, but the rates vary significantly, ranging from 5% to 80% in some cases.
  • Out-of-pocket spending limits: The total amount that a beneficiary is required to pay for a prescription (including deductibles, co-payments, co-insurance, and other out of pocket expenses), after which the insurer covers 100% of prescription drug costs. Not all plans have out-of-pocket spending limits and when they do there is great variation.
  • Plan spending limits or caps: The total amount that a plan will cover for any given beneficiary over a year or a lifetime, after which the beneficiary must pay 100% of prescription drug costs. Even if your drug is covered by your insurance, you must always verify what the value of the cap is. Costly drugs may reach the annual cap very quickly.
  • Formulary: List of all prescription medications covered by the plan.
  • Claim: Formal request to the insurance provider for payment of a benefit.
  • DIN: Drug Identification Number. Once a drug has been assigned a DIN, it means that it has undergone a successful Health Canada review process and it currently authorized for sale in Canada.

How is the cost of a medication decided?

The maximum allowable prices of all patented medicines in Canada are set by a federal agency, the Patented Medicines Prices Review Board (PMPRB). This board sets the limit for the price of new medicines based on its assessment of the therapeutic value the product brings, and by doing a comparison of prices with existing products in Canada and the price of these products in other countries. Once the acceptable limit is set, insurance companies and provinces will negotiate the cost with manufacturers.

Private Health Insurance

What is a private health insurance plan?

  • Insurance companies create benefit plans which are offered to employees by their employers. These plans cover innovative medicines and vaccines to help employers support the health and wellness of their employees and their families. Benefit plans allow employers to sustain a healthy and productive workplace and help them retain quality employees, improve morale and demonstrate social responsibility.

Who benefits from private insurance?

  • More than 23 million Canadians depend on access to medicines and vaccines through employer-sponsored private plans.
  • Why do employers offer benefit plans?

  • Ensuring access to the latest innovative medicines leads to better health. Employers pick medications based on their values and they are most likely to pick plans that keep their employees (and their families) happy, healthy and productive. Benefit plans are a major part of compensation packages and help attract and retain employees. Private drug plans may also be tax efficient as the employee usually receive the benefits tax-free and they are a full deduction for the employer.  
  • What is the difference between public and private plans?

  • 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.
  • Which prescriptions are covered?

  • 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.

  • Cap and Limits : It is important to clearly understand what portion, if any, that you are responsible for paying. You should also understand yearly or life-time limits or caps. Many of the newer innovative medication are quite expensive and it is good to understand your personal situation

    Generic or brand name?

    • Some plans are known as “mandatory generic,” indicating that the medicine will be automatically substituted for generic, or you must pay the difference in price between generic and brand name.
    • If the generic drug is ineffective for you or you cannot tolerate it, your physician can indicate “no substitution” on the prescription. In this case, your plan may cover the cost of the brand name drug. The insurance company may request that the physician provides medical evidence in this case.
    • You also have the option to pay for the brand name medication out of pocket without appealing. 

    Why is there a delay in getting my medication?

    • 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.

    How can I minimize delays in accessing medications?

    • 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.

    What is the cost of the claim?

  • 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.
  • How do patients get reimbursed?

  • 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.
  • What if I am covered by more than one private plan?

  • 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.
  • What if I do not have access to health insurance via my employer?

  • 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.

  • Public Health Plans

    What is a public health plan?

    • Public plans are paid for and administered by provincial and territorial governments. Most plans cover medicines and vaccines for eligible groups, such as seniors, recipients of social assistance and individuals who have conditions associated with high drug costs. Some public plans also have programs to cover certain types of medications for particular health conditions such as diabetes and cancer. Drugs used in hospitals are also covered by public plans.
    • Every province has its own way of providing drug benefits and each province has multiple plans. Some are to cover one particular medication, and some have a formulary with thousands of drugs.
    • The federal government provides drug benefits for specific groups, such as its employees, native Canadians and the Canadian forces.

    Who is covered by a public health plan in Canada?

  • It is estimated that 13.1 million Canadians are enrolled in a public insurance plan in Canada. Considering that some individuals qualify for both private and public insurance programs, it is estimated that more than 34 million Canadians are eligible for some form of prescription drug coverage. However, approximately 4.1 million Canadians with no private insurance are eligible but not enrolled in a public plan.
  • Who is eligible for public health plans in 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.

    How are drugs added to the public formulary?

  • 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.
  • What do public plans cost?

  • Individuals enrolled in a public plan may be subject to out-of-pocket costs such as premiums, deductibles, co-payments and annual or lifetime caps. Additionally, some public programs have limited or reduced formularies that may result in out-of-pocket payment by the patient for certain medications.

  • Cap and Limits : It is important to clearly understand what portion, if any, that you are responsible for paying. You should also understand yearly or life-time limits or caps. Many of the newer innovative medication are quite expensive and it is good to understand your personal situation.

    What if a drug is not covered by the formulary?

    • Ask your doctor about potential alternatives.
    • In most provinces or territories, you can request a formulary exception. For example, in Ontario there is the Exceptional Access Program which will help patients pay for drugs not covered by the Ontario Drug Benefit.
    • Look into patient assistance programs run by the manufacturer. Some programs are also offered by not-for-profit health charities, hospitals and government health agencies. Some of these programs are designed to cover the cost of co-insurance. There is no industry standard for assistance programs, so they vary greatly. 
    • Look into payment assistance programs. Some drug companies offer programs that provide discounts on their medications.
    • Learn more about compassionate assistance. It is used in rare situations to help patient’s access their medication. It acts as a bridge during uncertain times when a patient may not be able to afford the product.
    • Look into programs that provide savings on brand name medication, such as www.RxHelp.ca.


    Public Programs by Province and Territory

    Alberta

    Programs and eligibility:

    • Non-Group Coverage: Available to all Alberta residents under the age of 65.
    • Coverage for Seniors Benefit: residents over the age of 65.
    • Alberta Adult Health Benefit: For low-income Albertans.
    • Alberta Child Health Benefit: for low-income families to get coverage for their kids.
    • The complete list can be found here

    Enrollment:

    • Residents must apply in order to be enrolled.
    • While all residents are eligible under the Non-Group Coverage and Senior’s benefit, only 17.2% of Albertans are enrolled in a public program.

    Costs:

    • According to their website, only the Non-Group Coverage charges a monthly premium. It is set at $63.50 per month for an individual. However, it may vary based on family members and subsidy program assistance. More information can be found 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.

    For complete details, please refer to Alberta’s website

    British Columbia

    Programs and Eligibility:

    • Fair PharmaCare: Available for all BC residents who have Medical Services Plan Coverage and give PharmaCare permission to check their income with the CRA.
    • BC has seven addition plans to cover particular situations including cystic fibrosis, palliative care and psychiatric medications. For the list of plans ad eligibility, click here

    Enrollment

    • The Fair PharmaCare Plan requires application online or by phone. Other plans vary.
    • All residents are covered under a public program and 73% are enrolled in a program.

    Costs

    • Families enrolled in Fair PharmaCare must pay a deductible. Once it is reached, PharmaCare pays 70-75% of the costs. Once the family reaches their annual family maximum, Pharmacare will pay the rest. You can estimate your deductible and maximum here
    • Costs associated with other plans can be found on their website.

    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 complete details, refer to BC’s Pharmacare website.

    Manitoba

    Programs and Eligibility

    • 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

    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

    New Brunswick

    Programs and Eligibility

    • 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

    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.

    Newfoundland and Labrador

    Programs and Eligibility

    • 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

    Nova Scotia

    Programs and Eligibility

    • 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

    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

    Programs and Eligibility

    • 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

    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

    For more information, please see Ontario’s website

    Prince Edward Island

    Programs and Eligibility:

    • 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

    Québec

    Programs and Eligibility

    • 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

    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

    Programs and Eligibility

    • 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

    Government of Canada: Indigenous Health

    • 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

    Northwest Territories

    • 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.
    • 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.

    Nunavut

    • In Nunavut, the Non-Insured Health Benefits (NIHB) program is administered between Health Canada’s Northern Region Office and the Health Insurance Programs Office in Rankin Inlet. The NIHB covers eligible prescriptions for residents of Canada who are one of the following:
      • An Inuk recognized by one of the Inuit Land Claim Organizations
      • A registered Indian according to the Indian Act
      • An infant less than one year of age, whose parent is an eligible recipient
    • The Extended Health Benefits (EHB) is available for Nunavut residents with a valid Nunavut Health Care card who are
      • Non-indigenous residents with one of the specified conditions
      • Non-indigenous residents who are seniors (65+)
      • All residents who have exhausted their third-party insurance or have no medical travel benefits.

    Yukon

    • 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

    Advocating for Yourself

    Issues can arise even if you have insurance either privately or through your employer. As mentioned, the reimbursement world is complicated but not impossible to be successful. Stay positive, be relentless and engage your support network to help.

    We have included some helpful tips to help deal with common insurance issues – keep in mind you are not alone and it’s not personal.

    Private Insurance (insurance through an employer or privately purchased)

    • Understand the details of the employers group benefits package. If it’s not clear, reach out directly to a consultant at the insurance company. It is their job to help you.
    • Understand from your human resources department what to expect when making a claim, how to make a claim and where to go for help.  
    • If you (or your partner) leave your employer; in most cases, your benefits will also terminate (you will no longer have your medications/services available to you). If you (or your partner) are not going to a new employer which offers benefits, you will need to research other options for private individual insurance in your province.
      • If time permits, understand as far in advance what your coverage and access look like. If you (or your partner) are changing companies and they will have private insurance benefits, make sure your medication is on the employer purchased plan.

    Rejected insurance claim?

    • 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.

    Have insurance but the medication or treatment is not covered?

    • 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.

    Even when you feel you have exhausted all your options, many people have eventually been successful by not giving up. Continue building your case and how your condition impacts your life.

    Resources

    Prior Authorization: https://www.consumeraffairs.com/news/my-pharmacist-says-he-needs-prior-authorization-whats-that-all-about-040615.htm

    Step Therapy: http://prescriptionprocess.com/barriers-to-access/step-therapy/

    Cost Containment : https://www.claimsecure.com/cost-containment-services/clinical-services/

    Case Management: https://www.investopedia.com/terms/c/case-management.asp

    RAMQ – Private Plan information : https://www.ramq.gouv.qc.ca/en/citizens/prescription-drug-insurance/information-private-plans

    ODBF Formulary : http://www.health.gov.on.ca/en/pro/programs/drugs/odbf/odbf_formulary.aspx

    CADTH : https://www.cadth.ca/about-cadth/what-we-do/products-services/hta

    Insurance tips for drugs without coverage : https://www.goodrx.com/blog/drug-not-covered-insurance-tips-tactics/