Prescription Drugs
Prescription drugs are medications that can only be dispensed by a licensed pharmacist with a valid prescription from a qualified healthcare professional, such as a physician or nurse practitioner. These drugs are used to treat, manage, or prevent medical conditions and form one of the core components of most extended health care insurance plans. Prescription drug coverage helps offset the cost of medications that are not funded by provincial or territorial health programs.
How It Works
In Canada, coverage for prescription drugs falls into four categories: a federal program, provincial drug plans, employer-sponsored group health benefits, and private health insurance. Under the Canada Health Act, prescription drugs administered to an eligible patient in a Canadian hospital setting are provided at no cost, but drug coverage outside of hospital is up to each province or territory to establish. Because public drug coverage varies and some Canadians have effectively none outside hospital, many people supplement it through workplace group benefits or an individual private health insurance plan.
To be eligible for coverage under a Canadian health insurance plan, a prescription drug generally must be prescribed by a physician, dentist or psychiatrist, be medically necessary, and have an associated Drug Identification Number (DIN). Drug coverage from employee group benefits usually has no maximum, while personal individual health insurance plans tend to apply calendar-year and lifetime maximums on prescription drug coverage. Provincial plans manage drug costs through generic substitution; for example, British Columbia PharmaCare's Low Cost Alternative program covers the less costly version when the same drug is sold by more than one manufacturer.
Example:
A Canadian who takes a daily blood-pressure medication and lives outside hospital will not have it covered automatically by their provincial health card. If they have a workplace group benefits plan or an individual health and dental plan that includes prescription drug coverage, the plan helps pay for the medication as long as it is prescribed by a physician, is medically necessary, and carries a Drug Identification Number (DIN). A group plan may have no annual maximum, while an individual plan might cap the prescription drug benefit per calendar year, and the plan may cover the lower-cost generic version when one is available.
What to Watch For:
Not all drugs that meet the basic eligibility rules are covered; common exclusions are "lifestyle" drugs such as smoking cessation aids, fertility, weight loss and contraceptive drugs. Canada's national pharmacare covers a range of birth control options and diabetes medications, including the dispensing fee, but only for residents of provinces and territories that have reached a funding agreement with the federal government. Prescription drug costs account for the largest share of Canadian health benefit claims, underscoring how often Canadians rely on this coverage.
