A majority of Canadians (about 60% nationally) have private insurance/third-party insurance for prescription drugs as part of the group health benefits provided by their employers. Most plans also cover the employee's family/dependants. Employers purchase these plans from insurance companies and determine the terms of the plans (what drugs are covered, how much of the cost of the drug the plan covers, etc.)
Will my drug benefit plan pay for my prescription?
Private insurance plans will cover some or all of your prescription medications that are used on an outpatient basis. This can include oral, inhaled and injectable medications, or some drugs for intravenous infusion (infused at home or at a clinic). Private plans do not usually pay for medications used for patients staying in the hospital (in-patients).
If you are not sure if a medication is covered by your private insurance plan, phone your insurance carrier before you go to the pharmacy to determine the extent of your coverage. You will need to supply the insurance company with your policy number or group health benefits number (if you do not know this number, the Human Resources manager at your employer will have it). You will also need to know the drug indentification number (DIN) of the particular medication you are prescribed.
Generic Substitution - When there is more than one brand of medication available, which contain identical medicinal ingredients, some insurance plans will provide full coverage for the original brand. Some insurance plans will provide full coverage for the lowest cost generic alternative only. If a patient is unable to tolerate or has failed treatment under a generic drug, the treating physician can indicate "No Substitution" when prescribing, and the cost of the brand-name drug may be covered by the plan.
Don't know the DIN of your medication?
If you want to find out the DIN for a certain medication, click on the button below, select the DIN button and type in the drug name.
Is your plan not covering a drug you have been prescribed?
If your plan will not pay for a medication or if the insurance company refused a special authorization claim for a drug, here are some suggestions that may help you get the medication paid for. Click here.
Private Insurance Plans
Private insurance plans can differ greatly in terms of the drugs they cover, the extent of coverage, deductibles, copays and caps. Place your cursur on any of the bolded words to get an explanation of the term. Plans can be "open access" - they cover all prescription medications that are approved by Health Canada when used on an outpatient basis and prescribed by a licensed physician. Other plans cover drugs on a specific formulary that the employer has agreed to (formulary plans/managed care plans).
An insurance company may decide to establish guidelines for the coverage of a particular drug that is listed on some or all of their plans. For some drugs the insurance company requires the patient's physician to submit a letter giving details of the patient's illness and explaining why the drug is needed. The insurance company may then grant special authorization for the drug to be covered by the group health plan. It is important to provide the insurance company with all the necessary clinical information in order to make a decision for the claim and avoid delays. Contact the insurance carrier to find out if they require specific clinical information to process special authorization claims for your prescription medication (you will need your policy number and the DIN - drug identification number)
Individuals covered by group health benefit plans usually claim reimbursement for prescription drugs in one of two ways. Some plans issue pay direct cards that allow the cost of the drug to be billed directly to the insurance company through the pharmacy's billing system (less any deductible or copay that the individual may be personally responsible for). Some individuals pay for their medication at the pharmacy and then submit a claim form to the insurance company for reimbursement.
For a directory of Canadian insurance companies, click here.
For The Canadian Life and Health Insurance Association (CLHIA) Website, click here.