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Which Prescription Drugs are Covered by Health Insurance Plans?

Medicine is the practice of diagnosis, treatment, and prevention of disease and it keeps evolving at an amazing pace to benefit us all. When it comes to medication, there are more options than ever. But are you covered?

When it comes to threats to our health, many diseases are communicable, while others can be spontaneous, environmental, or genetic. Some ailments can be cured with rest and minimal intervention, but others rely on medication.

Thankfully, health insurance plans can include prescription drug coverage. Why? Publicly-funded government drug programs generally provide drug plan coverage only for those most in need, based on age, income, and medical condition. Most Canadians and their family members must pay the full cost of prescription drugs out of pocket, unless they have the benefit of health insurance prescription drug coverage in place.

Many health insurance plans will cover a portion of the cost for most prescription medications, but there are some that may not be covered.

What Types of Medication Are There?

To understand what health insurance may or may not cover, it is important to understand the types of medication available. In Canada, drugs can be sold only if they are a certain “schedule” or category. According to the National Association of Pharmacy Regulatory Authorities (NAPRA), medications are reviewed and assigned a schedule depending on their ingredients.

The schedule assigned specifies whether or not the drug would require a prescription.

What Will My Health Insurance Plan Cover?

Most health insurance companies will cover many drugs that are classified as Schedule 1 and require a prescription, with some restrictions.

Examples of common prescription drugs that are covered by health insurance plans are

  • high blood pressure (hypertension) medications
  • drugs used to control high cholesterol levels
  • insulin for diabetics.

Your health insurance plan may require you to pay a portion of your prescription costs, have an annual plan maximum, and may or may not cover the full dispensing fee.

Over the counter (OTC) drugs are also common medication purchases, but are usually not covered under a health insurance plan. Even if your doctor gives you a prescription for an OTC drug, your plan will not pay for it.

If you are in the hospital, drugs you receive are not covered by your health insurance. Those medications are covered under your provincial plan.

“Lifestyle drugs”  such as smoking cessation aids, fertility drugs, or erectile dysfunction drugs may or may not be covered, depending on your health insurance plan.

Allergy shots may be covered if administered by your doctor, but not all plans will cover these. They would need to list the Drug Identification Number (DIN) in order to be eligible. Similarly, vaccines for travel purposes may or may not be covered. Your regular flu shots and other vaccines are paid under your provincial plan, depending on where you live.

Many health insurance plans will not cover the costs of a brand name prescription drug if there is an equivalent generic drug available. You can read our blog Why does my health plan only cover the cost of generic drugs? for more insight on generic vs. brand name drugs.

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Unsure whether your prescription is covered? Ask us at SBIS.

If you are given a prescription and are uncertain if it is covered by your plan, you can:

  • refer to your policy for coverage details and exclusions
  • call our office and we can look the information up for you (we will need its Drug Identification Number or DIN).
  • check with your pharmacist (have your drug card on hand)

Most importantly, through careful design, you can be sure your health insurance will cover you for a wide range of prescription drugs while remaining affordable within your budget and protecting you from unexpected out-of-pocket medication costs.

Don’t let medication costs stand in the way of your good health

A health insurance plan can help cover out-of-pocket costs for prescription drugs that you and your family need, and take care of other health care expenses like:

  • Dental care
  • Vision care
  • Physiotherapy
  • Massage Therapy
  • Travel medical
  • Homecare
  • Hospital accommodation

At SBIS, we care about your health and want you to know what your options are. Prescription medication is an important part of many people’s lives. Having an insurance plan that helps pay for the cost of prescriptions and more can make life a little even if you have a pre-existing condition.

Want to ask a question or talk to an expert so you can put your individual health insurance plan in place? At SBIS, we are ready to help. Give us a call today at 1-800-667-0429 Monday to Friday, 8:45 a.m. to 4:45 p.m. ET.

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