Prescription drug costs are not covered by government health plans for most Canadians. For instance, you will qualify for the Ontario Drug Benefit (ODB) program only when you turn 65 years old, or if you require special care. If you are 24 years of age or younger and not covered by a private insurance plan you are eligible for OHIP+. Even with this government protection, your prescription may not be covered because government programs typically have fewer eligible medications.
But what about everyone else? You will need to pay out-of-pocket for prescription drug costs if you are not covered by a health insurance plan. But remember, it’s best to get your health insurance plan in place before you require any prescriptions.
What are the out-of-pocket costs?
Some drugs are more expensive than others, but even if they cost little, they still add up as time goes by. On the other hand, there are drugs that are so expensive that an insurance plan is absolutely necessary. Treatments for Crohn’s Disease, Ulcerative Colitis, and Psoriatic Arthritis and other high-cost medications often need pre-approval, along with a doctor’s recommendation stating the patient’s diagnosis.
The same applies treatment for Diabetes, which thousands of Canadians depend on to survive. Thankfully, health insurance is there to help alleviate the financial burdens that come with necessary medication.
You must pay immediately for drug costs, unless you have a drug card
With prescription drug health insurance, you will have a ‘drug card’ for your coverage. In the “olden days” you would have to pay the pharmacy and mail the receipt to the insurance company. Payment would take weeks. Nowadays, your plan’s drug card makes it easier for you to claim through your insurance. Just present the card to the pharmacist and you’re set. Depending on the percentage your plan pays for drugs, you will only be required to pay the difference.
Which prescription drugs are covered by health insurance?
Most health insurance plans cover many drugs that require a prescription like high blood pressure (hypertension) medications, drugs used to control high cholesterol levels and insulin for diabetics.
Here is how your coverage will work:
You may get a prescription for a certain brand name drug, but sometimes the pharmacy will give you the generic equivalent. Most plans cover generics without any problems, but if your doctor feels you should have no substitutes, they will need to say so in a note to the pharmacy. It doesn’t hurt to send this note to your insurance provider as well but remember that most plans will only pay up to the cost of the generic equivalent.
For more information on generic drugs, see Why Does My Health Plan Only Cover The Cost of Generic Drugs.
Typically, you are allowed a three-month supply of medication at a time. If you have a drug card, it’s programmed to cover this amount over a three-month time period. This means you cannot buy a three-month supply today and then another next week.
It’s an unfortunate reality that drug abuse occurs and as a direct result, so does insurance abuse. Your plan has measures in place to ensure that you are not exceeding the reasonable and customary amount that has been prescribed. Controlled substances are called “Schedule IV” drugs, which are dangerous but can have therapeutic uses.
If your insurance claims are reflecting an inordinate number of claims for opioids, your insurer may request information from your attending physician describing the condition being treated, how often you require the drug, and how long you are expected to be taking it.
This is not at all meant to embarrass or judge you; it’s meant to protect you and the insurance company itself, and the other individuals who are in the same insurance pool as you, to keep the costs down. Insurance is there to improve and enhance your health.
Insulin, Allergy Shots, Vaccines
If you have diabetes and rely on insulin, it may be included for coverage. The same goes for allergy shots and vaccines done at clinics. These types of drugs aren’t normally payable by drug card depending on where you get them, so you may need to send the receipt manually, or file your claim online.
Over The Counter (OTC) Drugs
Most plans only cover drugs that are unavailable over the counter. In some cases, however, there may be exceptions. Some creams require a medicated active ingredient in order to qualify for coverage.
For more details on what is and isn’t covered by prescription drug coverage, read this.
Your health insurance plan will help with other healthcare costs too
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
- Massage Therapy
- Travel medical
- Hospital accommodation
To choose your health insurance plan, it makes sense to get numerous health insurance quotes from different insurers, which as a leading broker for health and dental plans across Canada we do all that heavy lifting for you. Obtaining quotes from SBIS will help you select a plan that fits your budget and meets your needs.
You don’t need to worry about the rising costs of medication if you have a plan in place
Give us a call today at 1-800-667-0429 Monday to Friday, 8:45 a.m. to 4:45 p.m. ET. to find out how you can get a great health and dental insurance plan that includes robust drug coverage. 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 easier even if you have a pre-existing condition.