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Publicly Funded Drug Plans: Know your options

With different eligibility requirements, payment structures, and drug formularies for each plan, it can be a challenge to navigate the system and understand the publicly funded drug plans available to you.

Prescription drugs often play a significant role in health care. But how can you manage your treatment if you can’t handle the cost of these medications? With a little digging, you may be able to find a publicly funded drug plan that can help you.

The Canadian drug coverage system consists of 19 publicly funded plans: 6 federal plans, 10 provincial plans, and 3 territorial plans. As a result, prescription drug coverage options differ from province to province. With different eligibility requirements, payment structures, and lists called drug formularies for each plan, it can be a challenge to navigate the system and find the options available to you.

The sections below can help you understand what sort of publicly funded drug plans exist in Canada, how they work, and whether they might be right for you.

Federal drug coverage options
Basic provincial drug coverage options
Supplementary provincial drug coverage options
How do I access these plans?

Federal drug coverage options

The federal government provides prescription drug coverage options for specific population groups, such as public service employees, refugee claimants, federal inmates, and members of the Canadian Forces. Members of these groups are eligible for coverage if they do not have a private drug plan or do not qualify for their provincial or territorial drug plans. If you are eligible for federal drug benefits, you may receive full or partial coverage on your prescription medication.

The Library of Parliament provides information on the various federal drug benefit programs, including the levels of coverage.

Basic provincial drug coverage options

Some provincial and territorial governments offer basic drug coverage for all residents, regardless of health status, age or income. Most of these plans have a monthly or annual payment structure in place, and may require the resident to pay a portion of the medication costs. For example, any Alberta resident under the age of 65 (a separate senior’s drug program exists) can pay a monthly premium in order to get partial coverage for each prescription they fill.

In provinces where there is no universal drug program, such as Ontario, residents must pay for their own medications, unless they have private insurance, or qualify for one of the province’s supplementary drug programs.

The list of drugs that are covered by any provincial program will differ, as outlined by the provincial drug formulary.

Visit the Library of Parliament to find out if your province or territory offers a universal drug program.

Supplementary provincial drug coverage options

Many provinces and territories offer supplementary drug programs for specific age groups (seniors and children), people on social assistance, or people with certain diseases or conditions (such as HIV, cancer or diabetes).

Supplementary drug programs sometimes include a co-insurance or deductible structure, but these usually vary according to your income. For example, in Ontario, a high-income senior has a $100 deductible and pays $6.11 for each prescription, but a low-income senior or a person on social assistance will pay only $2 per prescription with no deductible.

In most provinces, programs for people on social assistance provide 100% drug coverage, but a few require a small co-insurance for each prescription filled. In New Brunswick, for example, a person on social assistance pays about $4.00 per prescription, up to a maximum of $250 per year.

Provincial programs for people with specific diseases or conditions may cover 100% of drug costs, depending on the type of disease. Keep in mind that the conditions may vary from province to province. For example, a resident of the Northwest Territories may access coverage for a wide variety of conditions, including arthritis and hypertension, whereas the Nova Scotia plans are limited to coverage for cancer and diabetes.

Don’t forget that prescription drug benefits are not universal in Canada, and each province or territory develops its own eligibility requirements for the programs it offers. Condition-based programs may also maintain their own formularies to determine which drugs are covered.

Learn more about provincial and territorial drug programs based on age, income or condition from the Library of Parliament.

How do I access these plans?

With the exception of provincial/territorial drug plans offered to the general public, most drug programs involve an application or qualification process. You will need to meet specific eligibility criteria, such as income or age requirements, in order to receive these benefits. For some of the programs directed at specific conditions, you can only access the program if your physician believes you are suitable, or if you receive treatment in a specific clinical setting.

For information on accessing the federal government’s drug coverage plans, visit Health Canada’s list of federal drug plans.

To determine which plans are available in your province or territory, and how to access them, select your provincial or territorial drug plan from the chart provided.

Key Websites:

• Health Canada: Insurance coverage for prescription medicines
• Parliament of Canada: Catastrophic drug coverage in Canada

Related Articles:

• Drug Lists: What do they tell you?
• Private Drug Insurance: Your coverage explained
• Drug Coverage: The Special Access Programme (SAP)
• Insurance Know-How: Defining payment terms

References