Public Coverage Options by Province

ON

Your health card

In order to receive publicly insured health care services you will need a provincial or territorial health insurance card – a health card. To get information about how to apply for a health card, visit the Ministry or Department of Health at:

Make sure you take your health card with you to all of your medical appointments. If you are eligible for prescription drug coverage under your provincial or territorial public plan, be sure to take your health card to the pharmacy when you are picking up your prescription drugs.

Public (Government) Drug Insurance Coverage

Check with your provincial or territorial ministry/department of health for details about the public health insurance plan, what services are covered, and if you are eligible to receive coverage for additional healthcare services, such as prescription medications. In some provinces and territories there are specific programs directed to certain groups of individuals that provide coverage for additional healthcare services. To find out if you qualify for public drug insurance coverage, visit your provincial or territorial prescription drug program.

Find out if your medication is covered through the Ontario Drug Benefit program by using the Check medication coverage tool.

Who pays for your medications and other healthcare treatments?

Depending on factors such as age, where you live and where you work, you may be covered, in all or part by either your provincial, territorial or federal public insurance plan. For others, treatments may be covered through your private benefits plan or that of a family member. For some people the only choice is to pay for the treatment out of your own pocket.

The eligibility for public plans is set by the respective government. Normally only Canadian citizens and permanent residents are eligible. Details on eligibility are available from the health ministry/department of the provincial or territorial government.

Provincial/ Territorial Health Insurance Plans

In Canada our publicly-funded universal health insurance system (“medicare”) is governed by the Canada Health Act. It covers physician services and a variety of medically necessary services when provided to a person while admitted to a hospital. The services of allied healthcare professionals, which are health professionals who are not doctors, are covered for a person in a hospital. The same is true for medications and diagnostic tests provided in a hospital.

Provinces and territories can choose to cover select health care costs in addition to physician services and health services in a hospital. For example, some provinces and territories offer coverage for prescription drugs or some allied (non-physician) health professionals for certain populations, or some in-home/home care services.

Discharge from hospital may change your coverage. For example, prescription drugs, nursing care, and physical therapy must be covered for patients while in hospital. However, there are considerable differences across province and territories in what is covered by the public insurance plan upon discharge from the hospital.

Difference in coverage among provinces and territories exists for medications and other treatments prescribed by a member of your treatment team when you are not a patient in hospital.

Each province, territory and some federal healthcare programs such as Veteran’s Affairs decides which drugs and allied healthcare services will be covered by public insurance plans. They also determine who is eligible for coverage under the public plan – often seniors and those with a low income or who require social assistance.

In hospitals, allied health services are covered. But outside the hospital, the availability of coverage for their services depends on your province or territory, the type of insurance you have, and sometimes qualifying characteristics like age.

What is a Formulary?

In your research to get information about your provincial/territorial or federal drug plan, you may have come across the term “formulary”. A formulary is the list of prescription medications or products that are covered under a public or private insurance plan.

The development of a formulary is based on a drug’s evaluations of efficacy (does it do what it is meant to do), safety and cost-effectiveness. Increasingly private insurance plan formularies tend to mirror the public plan formulary in their jurisdiction.

The federal/provincial and territorial governments together (except for Quebec) participate in a process called the Common Drug Review (CDR). The CDR reviews new drugs and makes a recommendation to the participants about coverage of a specific drug by the public drug benefit plans. It provides both clinical and economic reviews of new drugs. An expert committee gives evidence-based recommendations for whether new drugs should be included in a formulary. Each plan alone, though, ultimately decides whether to cover a new drug, based on the province/territory’s mandate, priorities and resources.

QC

Your health card

In order to receive publicly insured health care services you will need a provincial or territorial health insurance card – a health card. To get information about how to apply for a health card, visit the Ministry or Department of Health in your province or territory.

Make sure you take your health card with you to all of your medical appointments. If you are eligible for prescription drug coverage under your provincial or territorial public plan, be sure to take your health card to the pharmacy when you are picking up your prescription drugs.

Public (Government) Drug Insurance Coverage

Check with your provincial or territorial ministry/department of health for details about the public health insurance plan, what services are covered, and if you are eligible to receive coverage for additional healthcare services, such as prescription medications. In some provinces and territories there are specific programs directed to certain groups of individuals that provide coverage for additional healthcare services. To find out if you qualify for public drug insurance coverage, visit your provincial or territorial prescription drug program.

For reliable and free information about your treatment or a medication, use the Ask Your Pharmacist web app. This tool allows you to easily select, consult and ask questions to a pharmacist in your region. Please note that the use of the tool should never delay a medical consultation.

Who pays for your medications and other healthcare treatments?

Depending on factors such as age, where you live and where you work, you may be covered, in all or part by either your provincial, territorial or federal public insurance plan. For others, treatments may be covered through your private benefits plan or that of a family member. For some people the only choice is to pay for the treatment out of your own pocket.

The eligibility for public plans is set by the respective government. Normally only Canadian citizens and permanent residents are eligible. Details on eligibility are available from the health ministry/department of the provincial or territorial government.

Provincial/ Territorial Health Insurance Plans

In Canada our publicly-funded universal health insurance system (“medicare”) is governed by the Canada Health Act. It covers physician services and a variety of medically necessary services when provided to a person while admitted to a hospital. The services of allied healthcare professionals, which are health professionals who are not doctors, are covered for a person in a hospital. The same is true for medications and diagnostic tests provided in a hospital.

Provinces and territories can choose to cover select health care costs in addition to physician services and health services in a hospital. For example, some provinces and territories offer coverage for prescription drugs or some allied (non-physician) health professionals for certain populations, or some in-home/home care services.

Discharge from hospital may change your coverage. For example, prescription drugs, nursing care, and physical therapy must be covered for patients while in hospital. However, there are considerable differences across province and territories in what is covered by the public insurance plan upon discharge from the hospital.

Difference in coverage among provinces and territories exists for medications and other treatments prescribed by a member of your treatment team when you are not a patient in hospital.

Each province, territory and some federal healthcare programs such as Veteran’s Affairs decides which drugs and allied healthcare services will be covered by public insurance plans. They also determine who is eligible for coverage under the public plan – often seniors and those with a low income or who require social assistance.

In hospitals, allied health services are covered. But outside the hospital, the availability of coverage for their services depends on your province or territory, the type of insurance you have, and sometimes qualifying characteristics like age.

What is a Formulary?

In your research to get information about your provincial/territorial or federal drug plan, you may have come across the term “formulary”. A formulary is the list of prescription medications or products that are covered under a public or private insurance plan.

The development of a formulary is based on a drug’s evaluations of efficacy (does it do what it is meant to do), safety and cost-effectiveness. Increasingly private insurance plan formularies tend to mirror the public plan formulary in their jurisdiction.

The federal/provincial and territorial governments together (except for Quebec) participate in a process called the Common Drug Review (CDR). The CDR reviews new drugs and makes a recommendation to the participants about coverage of a specific drug by the public drug benefit plans. It provides both clinical and economic reviews of new drugs. An expert committee gives evidence-based recommendations for whether new drugs should be included in a formulary. Each plan alone, though, ultimately decides whether to cover a new drug, based on the province/territory’s mandate, priorities and resources.

NS

Your health card

In order to receive publicly insured health care services you will need a provincial or territorial health insurance card – a health card. To get information about how to apply for a health card, visit the Ministry or Department of Health in your province or territory.

Make sure you take your health card with you to all of your medical appointments. If you are eligible for prescription drug coverage under your provincial or territorial public plan, be sure to take your health card to the pharmacy when you are picking up your prescription drugs.

Public (Government) Drug Insurance Coverage

Check with your provincial or territorial ministry/department of health for details about the public health insurance plan, what services are covered, and if you are eligible to receive coverage for additional healthcare services, such as prescription medications. In some provinces and territories there are specific programs directed to certain groups of individuals that provide coverage for additional healthcare services. To find out if you qualify for public drug insurance coverage, visit your provincial or territorial prescription drug program.

Who pays for your medications and other healthcare treatments?

Depending on factors such as age, where you live and where you work, you may be covered, in all or part by either your provincial, territorial or federal public insurance plan. For others, treatments may be covered through your private benefits plan or that of a family member. For some people the only choice is to pay for the treatment out of your own pocket.

The eligibility for public plans is set by the respective government. Normally only Canadian citizens and permanent residents are eligible. Details on eligibility are available from the health ministry/department of the provincial or territorial government.

Provincial/ Territorial Health Insurance Plans

In Canada our publicly-funded universal health insurance system (“medicare”) is governed by the Canada Health Act. It covers physician services and a variety of medically necessary services when provided to a person while admitted to a hospital. The services of allied healthcare professionals, which are health professionals who are not doctors, are covered for a person in a hospital. The same is true for medications and diagnostic tests provided in a hospital.

Provinces and territories can choose to cover select health care costs in addition to physician services and health services in a hospital. For example, some provinces and territories offer coverage for prescription drugs or some allied (non-physician) health professionals for certain populations, or some in-home/home care services.

Discharge from hospital may change your coverage. For example, prescription drugs, nursing care, and physical therapy must be covered for patients while in hospital. However, there are considerable differences across province and territories in what is covered by the public insurance plan upon discharge from the hospital.

Difference in coverage among provinces and territories exists for medications and other treatments prescribed by a member of your treatment team when you are not a patient in hospital.

Each province, territory and some federal healthcare programs such as Veteran’s Affairs decides which drugs and allied healthcare services will be covered by public insurance plans. They also determine who is eligible for coverage under the public plan – often seniors and those with a low income or who require social assistance.

In hospitals, allied health services are covered. But outside the hospital, the availability of coverage for their services depends on your province or territory, the type of insurance you have, and sometimes qualifying characteristics like age.

What is a Formulary?

In your research to get information about your provincial/territorial or federal drug plan, you may have come across the term “formulary”. A formulary is the list of prescription medications or products that are covered under a public or private insurance plan.

The development of a formulary is based on a drug’s evaluations of efficacy (does it do what it is meant to do), safety and cost-effectiveness. Increasingly private insurance plan formularies tend to mirror the public plan formulary in their jurisdiction.

The federal/provincial and territorial governments together (except for Quebec) participate in a process called the Common Drug Review (CDR). The CDR reviews new drugs and makes a recommendation to the participants about coverage of a specific drug by the public drug benefit plans. It provides both clinical and economic reviews of new drugs. An expert committee gives evidence-based recommendations for whether new drugs should be included in a formulary. Each plan alone, though, ultimately decides whether to cover a new drug, based on the province/territory’s mandate, priorities and resources.

NB

Your health card

In order to receive publicly insured health care services you will need a provincial or territorial health insurance card – a health card. To get information about how to apply for a health card, visit the Ministry or Department of Health in your province or territory.

Make sure you take your health card with you to all of your medical appointments. If you are eligible for prescription drug coverage under your provincial or territorial public plan, be sure to take your health card to the pharmacy when you are picking up your prescription drugs.

Public (Government) Drug Insurance Coverage

Check with your provincial or territorial ministry/department of health for details about the public health insurance plan, what services are covered, and if you are eligible to receive coverage for additional healthcare services, such as prescription medications. In some provinces and territories there are specific programs directed to certain groups of individuals that provide coverage for additional healthcare services. To find out if you qualify for public drug insurance coverage, visit your provincial or territorial prescription drug program.

Who pays for your medications and other healthcare treatments?

Depending on factors such as age, where you live and where you work, you may be covered, in all or part by either your provincial, territorial or federal public insurance plan. For others, treatments may be covered through your private benefits plan or that of a family member. For some people the only choice is to pay for the treatment out of your own pocket.

The eligibility for public plans is set by the respective government. Normally only Canadian citizens and permanent residents are eligible. Details on eligibility are available from the health ministry/department of the provincial or territorial government.

Provincial/ Territorial Health Insurance Plans

In Canada our publicly-funded universal health insurance system (“medicare”) is governed by the Canada Health Act. It covers physician services and a variety of medically necessary services when provided to a person while admitted to a hospital. The services of allied healthcare professionals, which are health professionals who are not doctors, are covered for a person in a hospital. The same is true for medications and diagnostic tests provided in a hospital.

Provinces and territories can choose to cover select health care costs in addition to physician services and health services in a hospital. For example, some provinces and territories offer coverage for prescription drugs or some allied (non-physician) health professionals for certain populations, or some in-home/home care services.

Discharge from hospital may change your coverage. For example, prescription drugs, nursing care, and physical therapy must be covered for patients while in hospital. However, there are considerable differences across province and territories in what is covered by the public insurance plan upon discharge from the hospital.

Difference in coverage among provinces and territories exists for medications and other treatments prescribed by a member of your treatment team when you are not a patient in hospital.

Each province, territory and some federal healthcare programs such as Veteran’s Affairs decides which drugs and allied healthcare services will be covered by public insurance plans. They also determine who is eligible for coverage under the public plan – often seniors and those with a low income or who require social assistance.

In hospitals, allied health services are covered. But outside the hospital, the availability of coverage for their services depends on your province or territory, the type of insurance you have, and sometimes qualifying characteristics like age.

What is a Formulary?

In your research to get information about your provincial/territorial or federal drug plan, you may have come across the term “formulary”. A formulary is the list of prescription medications or products that are covered under a public or private insurance plan.

The development of a formulary is based on a drug’s evaluations of efficacy (does it do what it is meant to do), safety and cost-effectiveness. Increasingly private insurance plan formularies tend to mirror the public plan formulary in their jurisdiction.

The federal/provincial and territorial governments together (except for Quebec) participate in a process called the Common Drug Review (CDR). The CDR reviews new drugs and makes a recommendation to the participants about coverage of a specific drug by the public drug benefit plans. It provides both clinical and economic reviews of new drugs. An expert committee gives evidence-based recommendations for whether new drugs should be included in a formulary. Each plan alone, though, ultimately decides whether to cover a new drug, based on the province/territory’s mandate, priorities and resources.

MB

Your health card

In order to receive publicly insured health care services you will need a provincial or territorial health insurance card – a health card. To get information about how to apply for a health card, visit the Ministry or Department of Health in your province or territory.

Make sure you take your health card with you to all of your medical appointments. If you are eligible for prescription drug coverage under your provincial or territorial public plan, be sure to take your health card to the pharmacy when you are picking up your prescription drugs.

Public (Government) Drug Insurance Coverage

Check with your provincial or territorial ministry/department of health for details about the public health insurance plan, what services are covered, and if you are eligible to receive coverage for additional healthcare services, such as prescription medications. In some provinces and territories there are specific programs directed to certain groups of individuals that provide coverage for additional healthcare services. To find out if you qualify for public drug insurance coverage, visit your provincial or territorial prescription drug program.

Who pays for your medications and other healthcare treatments?

Depending on factors such as age, where you live and where you work, you may be covered, in all or part by either your provincial, territorial or federal public insurance plan. For others, treatments may be covered through your private benefits plan or that of a family member. For some people the only choice is to pay for the treatment out of your own pocket.

The eligibility for public plans is set by the respective government. Normally only Canadian citizens and permanent residents are eligible. Details on eligibility are available from the health ministry/department of the provincial or territorial government.

Provincial/ Territorial Health Insurance Plans

In Canada our publicly-funded universal health insurance system (“medicare”) is governed by the Canada Health Act. It covers physician services and a variety of medically necessary services when provided to a person while admitted to a hospital. The services of allied healthcare professionals, which are health professionals who are not doctors, are covered for a person in a hospital. The same is true for medications and diagnostic tests provided in a hospital.

Provinces and territories can choose to cover select health care costs in addition to physician services and health services in a hospital. For example, some provinces and territories offer coverage for prescription drugs or some allied (non-physician) health professionals for certain populations, or some in-home/home care services.

Discharge from hospital may change your coverage. For example, prescription drugs, nursing care, and physical therapy must be covered for patients while in hospital. However, there are considerable differences across province and territories in what is covered by the public insurance plan upon discharge from the hospital.

Difference in coverage among provinces and territories exists for medications and other treatments prescribed by a member of your treatment team when you are not a patient in hospital.

Each province, territory and some federal healthcare programs such as Veteran’s Affairs decides which drugs and allied healthcare services will be covered by public insurance plans. They also determine who is eligible for coverage under the public plan – often seniors and those with a low income or who require social assistance.

In hospitals, allied health services are covered. But outside the hospital, the availability of coverage for their services depends on your province or territory, the type of insurance you have, and sometimes qualifying characteristics like age.

What is a Formulary?

In your research to get information about your provincial/territorial or federal drug plan, you may have come across the term “formulary”. A formulary is the list of prescription medications or products that are covered under a public or private insurance plan.

The development of a formulary is based on a drug’s evaluations of efficacy (does it do what it is meant to do), safety and cost-effectiveness. Increasingly private insurance plan formularies tend to mirror the public plan formulary in their jurisdiction.

The federal/provincial and territorial governments together (except for Quebec) participate in a process called the Common Drug Review (CDR). The CDR reviews new drugs and makes a recommendation to the participants about coverage of a specific drug by the public drug benefit plans. It provides both clinical and economic reviews of new drugs. An expert committee gives evidence-based recommendations for whether new drugs should be included in a formulary. Each plan alone, though, ultimately decides whether to cover a new drug, based on the province/territory’s mandate, priorities and resources.

BC

Your health card

In order to receive publicly insured health care services you will need a provincial or territorial health insurance card – a health card. To get information about how to apply for a health card, visit the Ministry or Department of Health in your province or territory.

Make sure you take your health card with you to all of your medical appointments. If you are eligible for prescription drug coverage under your provincial or territorial public plan, be sure to take your health card to the pharmacy when you are picking up your prescription drugs.

Public (Government) Drug Insurance Coverage

Check with your provincial or territorial ministry/department of health for details about the public health insurance plan, what services are covered, and if you are eligible to receive coverage for additional healthcare services, such as prescription medications. In some provinces and territories there are specific programs directed to certain groups of individuals that provide coverage for additional healthcare services. To find out if you qualify for public drug insurance coverage, visit your provincial or territorial prescription drug program.

Who pays for your medications and other healthcare treatments?

Depending on factors such as age, where you live and where you work, you may be covered, in all or part by either your provincial, territorial or federal public insurance plan. For others, treatments may be covered through your private benefits plan or that of a family member. For some people the only choice is to pay for the treatment out of your own pocket.

The eligibility for public plans is set by the respective government. Normally only Canadian citizens and permanent residents are eligible. Details on eligibility are available from the health ministry/department of the provincial or territorial government.

Provincial/ Territorial Health Insurance Plans

In Canada our publicly-funded universal health insurance system (“medicare”) is governed by the Canada Health Act. It covers physician services and a variety of medically necessary services when provided to a person while admitted to a hospital. The services of allied healthcare professionals, which are health professionals who are not doctors, are covered for a person in a hospital. The same is true for medications and diagnostic tests provided in a hospital.

Provinces and territories can choose to cover select health care costs in addition to physician services and health services in a hospital. For example, some provinces and territories offer coverage for prescription drugs or some allied (non-physician) health professionals for certain populations, or some in-home/home care services.

Discharge from hospital may change your coverage. For example, prescription drugs, nursing care, and physical therapy must be covered for patients while in hospital. However, there are considerable differences across province and territories in what is covered by the public insurance plan upon discharge from the hospital.

Difference in coverage among provinces and territories exists for medications and other treatments prescribed by a member of your treatment team when you are not a patient in hospital.

Each province, territory and some federal healthcare programs such as Veteran’s Affairs decides which drugs and allied healthcare services will be covered by public insurance plans. They also determine who is eligible for coverage under the public plan – often seniors and those with a low income or who require social assistance.

In hospitals, allied health services are covered. But outside the hospital, the availability of coverage for their services depends on your province or territory, the type of insurance you have, and sometimes qualifying characteristics like age.

What is a Formulary?

In your research to get information about your provincial/territorial or federal drug plan, you may have come across the term “formulary”. A formulary is the list of prescription medications or products that are covered under a public or private insurance plan.

The development of a formulary is based on a drug’s evaluations of efficacy (does it do what it is meant to do), safety and cost-effectiveness. Increasingly private insurance plan formularies tend to mirror the public plan formulary in their jurisdiction.

The federal/provincial and territorial governments together (except for Quebec) participate in a process called the Common Drug Review (CDR). The CDR reviews new drugs and makes a recommendation to the participants about coverage of a specific drug by the public drug benefit plans. It provides both clinical and economic reviews of new drugs. An expert committee gives evidence-based recommendations for whether new drugs should be included in a formulary. Each plan alone, though, ultimately decides whether to cover a new drug, based on the province/territory’s mandate, priorities and resources.

PEI

Your health card

In order to receive publicly insured health care services you will need a provincial or territorial health insurance card – a health card. To get information about how to apply for a health card, visit the Ministry or Department of Health in your province or territory.

Make sure you take your health card with you to all of your medical appointments. If you are eligible for prescription drug coverage under your provincial or territorial public plan, be sure to take your health card to the pharmacy when you are picking up your prescription drugs.

Public (Government) Drug Insurance Coverage

Check with your provincial or territorial ministry/department of health for details about the public health insurance plan, what services are covered, and if you are eligible to receive coverage for additional healthcare services, such as prescription medications. In some provinces and territories there are specific programs directed to certain groups of individuals that provide coverage for additional healthcare services. To find out if you qualify for public drug insurance coverage, visit your provincial or territorial prescription drug program.

Who pays for your medications and other healthcare treatments?

Depending on factors such as age, where you live and where you work, you may be covered, in all or part by either your provincial, territorial or federal public insurance plan. For others, treatments may be covered through your private benefits plan or that of a family member. For some people the only choice is to pay for the treatment out of your own pocket.

The eligibility for public plans is set by the respective government. Normally only Canadian citizens and permanent residents are eligible. Details on eligibility are available from the health ministry/department of the provincial or territorial government.

Provincial/ Territorial Health Insurance Plans

In Canada our publicly-funded universal health insurance system (“medicare”) is governed by the Canada Health Act. It covers physician services and a variety of medically necessary services when provided to a person while admitted to a hospital. The services of allied healthcare professionals, which are health professionals who are not doctors, are covered for a person in a hospital. The same is true for medications and diagnostic tests provided in a hospital.

Provinces and territories can choose to cover select health care costs in addition to physician services and health services in a hospital. For example, some provinces and territories offer coverage for prescription drugs or some allied (non-physician) health professionals for certain populations, or some in-home/home care services.

Discharge from hospital may change your coverage. For example, prescription drugs, nursing care, and physical therapy must be covered for patients while in hospital. However, there are considerable differences across province and territories in what is covered by the public insurance plan upon discharge from the hospital.

Difference in coverage among provinces and territories exists for medications and other treatments prescribed by a member of your treatment team when you are not a patient in hospital.

Each province, territory and some federal healthcare programs such as Veteran’s Affairs decides which drugs and allied healthcare services will be covered by public insurance plans. They also determine who is eligible for coverage under the public plan – often seniors and those with a low income or who require social assistance.

In hospitals, allied health services are covered. But outside the hospital, the availability of coverage for their services depends on your province or territory, the type of insurance you have, and sometimes qualifying characteristics like age.

What is a Formulary?

In your research to get information about your provincial/territorial or federal drug plan, you may have come across the term “formulary”. A formulary is the list of prescription medications or products that are covered under a public or private insurance plan.

The development of a formulary is based on a drug’s evaluations of efficacy (does it do what it is meant to do), safety and cost-effectiveness. Increasingly private insurance plan formularies tend to mirror the public plan formulary in their jurisdiction.

The federal/provincial and territorial governments together (except for Quebec) participate in a process called the Common Drug Review (CDR). The CDR reviews new drugs and makes a recommendation to the participants about coverage of a specific drug by the public drug benefit plans. It provides both clinical and economic reviews of new drugs. An expert committee gives evidence-based recommendations for whether new drugs should be included in a formulary. Each plan alone, though, ultimately decides whether to cover a new drug, based on the province/territory’s mandate, priorities and resources.

SK

Your health card

In order to receive publicly insured health care services you will need a provincial or territorial health insurance card – a health card. To get information about how to apply for a health card, visit the Ministry or Department of Health in your province or territory.

Make sure you take your health card with you to all of your medical appointments. If you are eligible for prescription drug coverage under your provincial or territorial public plan, be sure to take your health card to the pharmacy when you are picking up your prescription drugs.

Public (Government) Drug Insurance Coverage

Check with your provincial or territorial ministry/department of health for details about the public health insurance plan, what services are covered, and if you are eligible to receive coverage for additional healthcare services, such as prescription medications. In some provinces and territories there are specific programs directed to certain groups of individuals that provide coverage for additional healthcare services. To find out if you qualify for public drug insurance coverage, visit your provincial or territorial prescription drug program.

Who pays for your medications and other healthcare treatments?

Depending on factors such as age, where you live and where you work, you may be covered, in all or part by either your provincial, territorial or federal public insurance plan. For others, treatments may be covered through your private benefits plan or that of a family member. For some people the only choice is to pay for the treatment out of your own pocket.

The eligibility for public plans is set by the respective government. Normally only Canadian citizens and permanent residents are eligible. Details on eligibility are available from the health ministry/department of the provincial or territorial government.

Provincial/ Territorial Health Insurance Plans

In Canada our publicly-funded universal health insurance system (“medicare”) is governed by the Canada Health Act. It covers physician services and a variety of medically necessary services when provided to a person while admitted to a hospital. The services of allied healthcare professionals, which are health professionals who are not doctors, are covered for a person in a hospital. The same is true for medications and diagnostic tests provided in a hospital.

Provinces and territories can choose to cover select health care costs in addition to physician services and health services in a hospital. For example, some provinces and territories offer coverage for prescription drugs or some allied (non-physician) health professionals for certain populations, or some in-home/home care services.

Discharge from hospital may change your coverage. For example, prescription drugs, nursing care, and physical therapy must be covered for patients while in hospital. However, there are considerable differences across province and territories in what is covered by the public insurance plan upon discharge from the hospital.

Difference in coverage among provinces and territories exists for medications and other treatments prescribed by a member of your treatment team when you are not a patient in hospital.

Each province, territory and some federal healthcare programs such as Veteran’s Affairs decides which drugs and allied healthcare services will be covered by public insurance plans. They also determine who is eligible for coverage under the public plan – often seniors and those with a low income or who require social assistance.

In hospitals, allied health services are covered. But outside the hospital, the availability of coverage for their services depends on your province or territory, the type of insurance you have, and sometimes qualifying characteristics like age.

What is a Formulary?

In your research to get information about your provincial/territorial or federal drug plan, you may have come across the term “formulary”. A formulary is the list of prescription medications or products that are covered under a public or private insurance plan.

The development of a formulary is based on a drug’s evaluations of efficacy (does it do what it is meant to do), safety and cost-effectiveness. Increasingly private insurance plan formularies tend to mirror the public plan formulary in their jurisdiction.

The federal/provincial and territorial governments together (except for Quebec) participate in a process called the Common Drug Review (CDR). The CDR reviews new drugs and makes a recommendation to the participants about coverage of a specific drug by the public drug benefit plans. It provides both clinical and economic reviews of new drugs. An expert committee gives evidence-based recommendations for whether new drugs should be included in a formulary. Each plan alone, though, ultimately decides whether to cover a new drug, based on the province/territory’s mandate, priorities and resources.

AB

Your health card

In order to receive publicly insured health care services you will need a provincial or territorial health insurance card – a health card. To get information about how to apply for a health card, visit the Ministry or Department of Health in your province or territory.

Alberta Health Services

Make sure you take your health card with you to all of your medical appointments. If you are eligible for prescription drug coverage under your provincial or territorial public plan, be sure to take your health card to the pharmacy when you are picking up your prescription drugs.

Public (Government) Drug Insurance Coverage

Check with your provincial or territorial ministry/department of health for details about the public health insurance plan, what services are covered, and if you are eligible to receive coverage for additional healthcare services, such as prescription medications. In some provinces and territories there are specific programs directed to certain groups of individuals that provide coverage for additional healthcare services. To find out if you qualify for public drug insurance coverage, visit your provincial or territorial prescription drug program.

Who pays for your medications and other healthcare treatments?

Depending on factors such as age, where you live and where you work, you may be covered, in all or part by either your provincial, territorial or federal public insurance plan. For others, treatments may be covered through your private benefits plan or that of a family member. For some people the only choice is to pay for the treatment out of your own pocket.

The eligibility for public plans is set by the respective government. Normally only Canadian citizens and permanent residents are eligible. Details on eligibility are available from the health ministry/department of the provincial or territorial government.

Provincial/ Territorial Health Insurance Plans

In Canada our publicly-funded universal health insurance system (“medicare”) is governed by the Canada Health Act. It covers physician services and a variety of medically necessary services when provided to a person while admitted to a hospital. The services of allied healthcare professionals, which are health professionals who are not doctors, are covered for a person in a hospital. The same is true for medications and diagnostic tests provided in a hospital.

Provinces and territories can choose to cover select health care costs in addition to physician services and health services in a hospital. For example, some provinces and territories offer coverage for prescription drugs or some allied (non-physician) health professionals for certain populations, or some in-home/home care services.

Discharge from hospital may change your coverage. For example, prescription drugs, nursing care, and physical therapy must be covered for patients while in hospital. However, there are considerable differences across province and territories in what is covered by the public insurance plan upon discharge from the hospital.

Difference in coverage among provinces and territories exists for medications and other treatments prescribed by a member of your treatment team when you are not a patient in hospital.

Each province, territory and some federal healthcare programs such as Veteran’s Affairs decides which drugs and allied healthcare services will be covered by public insurance plans. They also determine who is eligible for coverage under the public plan – often seniors and those with a low income or who require social assistance.

In hospitals, allied health services are covered. But outside the hospital, the availability of coverage for their services depends on your province or territory, the type of insurance you have, and sometimes qualifying characteristics like age.

What is a Formulary?

In your research to get information about your provincial/territorial or federal drug plan, you may have come across the term “formulary”. A formulary is the list of prescription medications or products that are covered under a public or private insurance plan.

The development of a formulary is based on a drug’s evaluations of efficacy (does it do what it is meant to do), safety and cost-effectiveness. Increasingly private insurance plan formularies tend to mirror the public plan formulary in their jurisdiction.

The federal/provincial and territorial governments together (except for Quebec) participate in a process called the Common Drug Review (CDR). The CDR reviews new drugs and makes a recommendation to the participants about coverage of a specific drug by the public drug benefit plans. It provides both clinical and economic reviews of new drugs. An expert committee gives evidence-based recommendations for whether new drugs should be included in a formulary. Each plan alone, though, ultimately decides whether to cover a new drug, based on the province/territory’s mandate, priorities and resources.

NL

Your health card

In order to receive publicly insured health care services you will need a provincial or territorial health insurance card – a health card. To get information about how to apply for a health card, visit the Ministry or Department of Health in your province or territory.

Make sure you take your health card with you to all of your medical appointments. If you are eligible for prescription drug coverage under your provincial or territorial public plan, be sure to take your health card to the pharmacy when you are picking up your prescription drugs.

Public (Government) Drug Insurance Coverage

Check with your provincial or territorial ministry/department of health for details about the public health insurance plan, what services are covered, and if you are eligible to receive coverage for additional healthcare services, such as prescription medications. In some provinces and territories there are specific programs directed to certain groups of individuals that provide coverage for additional healthcare services. To find out if you qualify for public drug insurance coverage, visit your provincial or territorial prescription drug program.

Who pays for your medications and other healthcare treatments?

Depending on factors such as age, where you live and where you work, you may be covered, in all or part by either your provincial, territorial or federal public insurance plan. For others, treatments may be covered through your private benefits plan or that of a family member. For some people the only choice is to pay for the treatment out of your own pocket.

The eligibility for public plans is set by the respective government. Normally only Canadian citizens and permanent residents are eligible. Details on eligibility are available from the health ministry/department of the provincial or territorial government.

Provincial/ Territorial Health Insurance Plans

In Canada our publicly-funded universal health insurance system (“medicare”) is governed by the Canada Health Act. It covers physician services and a variety of medically necessary services when provided to a person while admitted to a hospital. The services of allied healthcare professionals, which are health professionals who are not doctors, are covered for a person in a hospital. The same is true for medications and diagnostic tests provided in a hospital.

Provinces and territories can choose to cover select health care costs in addition to physician services and health services in a hospital. For example, some provinces and territories offer coverage for prescription drugs or some allied (non-physician) health professionals for certain populations, or some in-home/home care services.

Discharge from hospital may change your coverage. For example, prescription drugs, nursing care, and physical therapy must be covered for patients while in hospital. However, there are considerable differences across province and territories in what is covered by the public insurance plan upon discharge from the hospital.

Difference in coverage among provinces and territories exists for medications and other treatments prescribed by a member of your treatment team when you are not a patient in hospital.

Each province, territory and some federal healthcare programs such as Veteran’s Affairs decides which drugs and allied healthcare services will be covered by public insurance plans. They also determine who is eligible for coverage under the public plan – often seniors and those with a low income or who require social assistance.

In hospitals, allied health services are covered. But outside the hospital, the availability of coverage for their services depends on your province or territory, the type of insurance you have, and sometimes qualifying characteristics like age.

What is a Formulary?

In your research to get information about your provincial/territorial or federal drug plan, you may have come across the term “formulary”. A formulary is the list of prescription medications or products that are covered under a public or private insurance plan.

The development of a formulary is based on a drug’s evaluations of efficacy (does it do what it is meant to do), safety and cost-effectiveness. Increasingly private insurance plan formularies tend to mirror the public plan formulary in their jurisdiction.

The federal/provincial and territorial governments together (except for Quebec) participate in a process called the Common Drug Review (CDR). The CDR reviews new drugs and makes a recommendation to the participants about coverage of a specific drug by the public drug benefit plans. It provides both clinical and economic reviews of new drugs. An expert committee gives evidence-based recommendations for whether new drugs should be included in a formulary. Each plan alone, though, ultimately decides whether to cover a new drug, based on the province/territory’s mandate, priorities and resources.

YT

Your health card

In order to receive publicly insured health care services you will need a provincial or territorial health insurance card – a health card. To get information about how to apply for a health card, visit the Ministry or Department of Health in your province or territory.

Make sure you take your health card with you to all of your medical appointments. If you are eligible for prescription drug coverage under your provincial or territorial public plan, be sure to take your health card to the pharmacy when you are picking up your prescription drugs.

Public (Government) Drug Insurance Coverage

Check with your provincial or territorial ministry/department of health for details about the public health insurance plan, what services are covered, and if you are eligible to receive coverage for additional healthcare services, such as prescription medications. In some provinces and territories there are specific programs directed to certain groups of individuals that provide coverage for additional healthcare services. To find out if you qualify for public drug insurance coverage, visit your provincial or territorial prescription drug program.

Who pays for your medications and other healthcare treatments?

Depending on factors such as age, where you live and where you work, you may be covered, in all or part by either your provincial, territorial or federal public insurance plan. For others, treatments may be covered through your private benefits plan or that of a family member. For some people the only choice is to pay for the treatment out of your own pocket.

The eligibility for public plans is set by the respective government. Normally only Canadian citizens and permanent residents are eligible. Details on eligibility are available from the health ministry/department of the provincial or territorial government.

Provincial/ Territorial Health Insurance Plans

In Canada our publicly-funded universal health insurance system (“medicare”) is governed by the Canada Health Act. It covers physician services and a variety of medically necessary services when provided to a person while admitted to a hospital. The services of allied healthcare professionals, which are health professionals who are not doctors, are covered for a person in a hospital. The same is true for medications and diagnostic tests provided in a hospital.

Provinces and territories can choose to cover select health care costs in addition to physician services and health services in a hospital. For example, some provinces and territories offer coverage for prescription drugs or some allied (non-physician) health professionals for certain populations, or some in-home/home care services.

Discharge from hospital may change your coverage. For example, prescription drugs, nursing care, and physical therapy must be covered for patients while in hospital. However, there are considerable differences across province and territories in what is covered by the public insurance plan upon discharge from the hospital.

Difference in coverage among provinces and territories exists for medications and other treatments prescribed by a member of your treatment team when you are not a patient in hospital.

Each province, territory and some federal healthcare programs such as Veteran’s Affairs decides which drugs and allied healthcare services will be covered by public insurance plans. They also determine who is eligible for coverage under the public plan – often seniors and those with a low income or who require social assistance.

In hospitals, allied health services are covered. But outside the hospital, the availability of coverage for their services depends on your province or territory, the type of insurance you have, and sometimes qualifying characteristics like age.

What is a Formulary?

In your research to get information about your provincial/territorial or federal drug plan, you may have come across the term “formulary”. A formulary is the list of prescription medications or products that are covered under a public or private insurance plan.

The development of a formulary is based on a drug’s evaluations of efficacy (does it do what it is meant to do), safety and cost-effectiveness. Increasingly private insurance plan formularies tend to mirror the public plan formulary in their jurisdiction.

The federal/provincial and territorial governments together (except for Quebec) participate in a process called the Common Drug Review (CDR). The CDR reviews new drugs and makes a recommendation to the participants about coverage of a specific drug by the public drug benefit plans. It provides both clinical and economic reviews of new drugs. An expert committee gives evidence-based recommendations for whether new drugs should be included in a formulary. Each plan alone, though, ultimately decides whether to cover a new drug, based on the province/territory’s mandate, priorities and resources.

NT

Your health card

In order to receive publicly insured health care services you will need a provincial or territorial health insurance card – a health card. To get information about how to apply for a health card, visit the Ministry or Department of Health in your province or territory.

Make sure you take your health card with you to all of your medical appointments. If you are eligible for prescription drug coverage under your provincial or territorial public plan, be sure to take your health card to the pharmacy when you are picking up your prescription drugs.

Public (Government) Drug Insurance Coverage

Check with your provincial or territorial ministry/department of health for details about the public health insurance plan, what services are covered, and if you are eligible to receive coverage for additional healthcare services, such as prescription medications. In some provinces and territories there are specific programs directed to certain groups of individuals that provide coverage for additional healthcare services. To find out if you qualify for public drug insurance coverage, visit your provincial or territorial prescription drug program.

Who pays for your medications and other healthcare treatments?

Depending on factors such as age, where you live and where you work, you may be covered, in all or part by either your provincial, territorial or federal public insurance plan. For others, treatments may be covered through your private benefits plan or that of a family member. For some people the only choice is to pay for the treatment out of your own pocket.

The eligibility for public plans is set by the respective government. Normally only Canadian citizens and permanent residents are eligible. Details on eligibility are available from the health ministry/department of the provincial or territorial government.

Provincial/ Territorial Health Insurance Plans

In Canada our publicly-funded universal health insurance system (“medicare”) is governed by the Canada Health Act. It covers physician services and a variety of medically necessary services when provided to a person while admitted to a hospital. The services of allied healthcare professionals, which are health professionals who are not doctors, are covered for a person in a hospital. The same is true for medications and diagnostic tests provided in a hospital.

Provinces and territories can choose to cover select health care costs in addition to physician services and health services in a hospital. For example, some provinces and territories offer coverage for prescription drugs or some allied (non-physician) health professionals for certain populations, or some in-home/home care services.

Discharge from hospital may change your coverage. For example, prescription drugs, nursing care, and physical therapy must be covered for patients while in hospital. However, there are considerable differences across province and territories in what is covered by the public insurance plan upon discharge from the hospital.

Difference in coverage among provinces and territories exists for medications and other treatments prescribed by a member of your treatment team when you are not a patient in hospital.

Each province, territory and some federal healthcare programs such as Veteran’s Affairs decides which drugs and allied healthcare services will be covered by public insurance plans. They also determine who is eligible for coverage under the public plan – often seniors and those with a low income or who require social assistance.

In hospitals, allied health services are covered. But outside the hospital, the availability of coverage for their services depends on your province or territory, the type of insurance you have, and sometimes qualifying characteristics like age.

What is a Formulary?

In your research to get information about your provincial/territorial or federal drug plan, you may have come across the term “formulary”. A formulary is the list of prescription medications or products that are covered under a public or private insurance plan.

The development of a formulary is based on a drug’s evaluations of efficacy (does it do what it is meant to do), safety and cost-effectiveness. Increasingly private insurance plan formularies tend to mirror the public plan formulary in their jurisdiction.

The federal/provincial and territorial governments together (except for Quebec) participate in a process called the Common Drug Review (CDR). The CDR reviews new drugs and makes a recommendation to the participants about coverage of a specific drug by the public drug benefit plans. It provides both clinical and economic reviews of new drugs. An expert committee gives evidence-based recommendations for whether new drugs should be included in a formulary. Each plan alone, though, ultimately decides whether to cover a new drug, based on the province/territory’s mandate, priorities and resources.

NU

Your health card

In order to receive publicly insured health care services you will need a provincial or territorial health insurance card – a health card. To get information about how to apply for a health card, visit the Ministry or Department of Health in your province or territory.

Make sure you take your health card with you to all of your medical appointments. If you are eligible for prescription drug coverage under your provincial or territorial public plan, be sure to take your health card to the pharmacy when you are picking up your prescription drugs.

Public (Government) Drug Insurance Coverage

Check with your provincial or territorial ministry/department of health for details about the public health insurance plan, what services are covered, and if you are eligible to receive coverage for additional healthcare services, such as prescription medications. In some provinces and territories there are specific programs directed to certain groups of individuals that provide coverage for additional healthcare services. To find out if you qualify for public drug insurance coverage, visit your provincial or territorial prescription drug program.

Who pays for your medications and other healthcare treatments?

Depending on factors such as age, where you live and where you work, you may be covered, in all or part by either your provincial, territorial or federal public insurance plan. For others, treatments may be covered through your private benefits plan or that of a family member. For some people the only choice is to pay for the treatment out of your own pocket.

The eligibility for public plans is set by the respective government. Normally only Canadian citizens and permanent residents are eligible. Details on eligibility are available from the health ministry/department of the provincial or territorial government.

Provincial/ Territorial Health Insurance Plans

In Canada our publicly-funded universal health insurance system (“medicare”) is governed by the Canada Health Act. It covers physician services and a variety of medically necessary services when provided to a person while admitted to a hospital. The services of allied healthcare professionals, which are health professionals who are not doctors, are covered for a person in a hospital. The same is true for medications and diagnostic tests provided in a hospital.

Provinces and territories can choose to cover select health care costs in addition to physician services and health services in a hospital. For example, some provinces and territories offer coverage for prescription drugs or some allied (non-physician) health professionals for certain populations, or some in-home/home care services.

Discharge from hospital may change your coverage. For example, prescription drugs, nursing care, and physical therapy must be covered for patients while in hospital. However, there are considerable differences across province and territories in what is covered by the public insurance plan upon discharge from the hospital.

Difference in coverage among provinces and territories exists for medications and other treatments prescribed by a member of your treatment team when you are not a patient in hospital.

Each province, territory and some federal healthcare programs such as Veteran’s Affairs decides which drugs and allied healthcare services will be covered by public insurance plans. They also determine who is eligible for coverage under the public plan – often seniors and those with a low income or who require social assistance.

In hospitals, allied health services are covered. But outside the hospital, the availability of coverage for their services depends on your province or territory, the type of insurance you have, and sometimes qualifying characteristics like age.

What is a Formulary?

In your research to get information about your provincial/territorial or federal drug plan, you may have come across the term “formulary”. A formulary is the list of prescription medications or products that are covered under a public or private insurance plan.

The development of a formulary is based on a drug’s evaluations of efficacy (does it do what it is meant to do), safety and cost-effectiveness. Increasingly private insurance plan formularies tend to mirror the public plan formulary in their jurisdiction.

The federal/provincial and territorial governments together (except for Quebec) participate in a process called the Common Drug Review (CDR). The CDR reviews new drugs and makes a recommendation to the participants about coverage of a specific drug by the public drug benefit plans. It provides both clinical and economic reviews of new drugs. An expert committee gives evidence-based recommendations for whether new drugs should be included in a formulary. Each plan alone, though, ultimately decides whether to cover a new drug, based on the province/territory’s mandate, priorities and resources

Private Insurance Information

The insurance company administers the plans and pays the claims according to the plan the plan sponsor has purchased.

The plan member is the individual who receives the benefits – you.

Private or employee benefit plans are created by the plan sponsor who, with the advice of the insurance consultant, determines the services and level of coverage and purchases the group benefit plan from an insurance company. Sometimes a plan sponsors does not use a consultant and sometimes the insurance company will help with the design of the plan.

If you are part of a group benefit plan either through your employer or a family member’s employer, your union or an association, you typically receive an information booklet or access to a website about the healthcare services that are covered. Services may range from prescription medications to extended healthcare services that include:

  • additional hospital coverage (ex. a private room)
  • out-of-country coverage
  • “allied healthcare” (physiotherapy, counselling, chiropractic, etc)
  • equipment such as eye glasses, orthotics, etc
  • dental services

Will my group benefit plan pay for my prescription medication?
Each plan is different, based on the size of the group, the objectives of the plan sponsor and of course the budget. A formulary usually exists to determine what each plan will pay for.

To learn about what your plan has to offer review the information provided by your employer and its insurance company. In the case of prescription medications, some insurance companies will offer an online tool to look up drugs to check if they are covered.

If you are still unsure if your medication is covered by your private insurance plan, feel free to call your insurance company before you go to the pharmacy to determine your coverage. Many plans have a web-based service that tells the pharmacist how much is covered and how much you will need to pay.

You’ll have to give the insurance company or pharmacist your policy number or group health benefits number. (If you can’t find the number, contact your human resources department or employer.) It’s helpful to know the drug identification number (DIN) as well when contacting the insurance company. You can get the DIN from your prescribing physician.

Information about your insurance policy may also be found on the insurance company website in a section dedicated to members. You will have to register on the site to be able to access this information.

When a private insurance plan covers you, you can generally claim reimbursement for prescription drugs in one of two ways.

  1. Most plans issue an insurance card. Take the card with you tothe pharmacy and the cost of the drug will be billed directly to your insurer, through the pharmacy’s billing system. You will still have to pay any deductible or copay. To learn more about these types of out-of-pocket expenses, go to Plan Member Payments below.
  2. In some cases, you will have to pay for your drugs at the pharmacy and then submit the receipt along with an insurance form to your insurer who will reimburse you.

If you are having difficulty getting a drug you need covered by your insurance company, go the Other Options tab.

If you do you do not have access to a group benefit plan, it’s possible to buy an individual or family health plan. Consult an insurance broker/consultant for details about these plans. Some associations and groups offer group health insurance plans, such as the Canadian Association for Retired Persons, Canadian Automobile Association. The advantage of group coverage is that costs can be shared over a larger number of plan members, which could mean a lower premium for you.

Plan member payments – additional costs that you, the plan member, may have to pay

If you are part of a health insurance plan, whether public, private or individual, there are likely additional costs you’ll have to pay when you make a claim or seek reimbursement for a benefit. Here are the key terms for financial matters related to health insurance:

  • Benefit: Payment by insurance company after approving a claim.Claim: Formal request to the insurance provider for payment of a benefit.
  • Coinsurance: Arrangement in a health insurance plan where you and the insurance company share the cost of the items covered. You usually pay a set percentage (say 20%) and the remainder (80%) is paid by the insurance plan.
  • Copayment or Copay: A predetermined fee a plan member pays for healthcare services. This amount is usually a flat fee.
  • Deductible: Amount that plan members pay before the insurance kicks in. For example, you might have an annual $500 deductible, meaning you cover the first $500 for health services before your insurance company begins to pay. Or, there may be a set deductible for each prescription drug.
  • Premium: A fee paid to the insurance company or health plan to provide insurance coverage. Depending on your type of plan, this may be paid, in all or part, by a third party such as your employer.

Coordinate your benefits coverage

If you are covered by more than one benefit plan, you may be able to minimize the amount you pay. This most often occurs when you and your spouse each have a plan, or a child covered by your plan grows up, gains employment, and has a plan. It can be tricky to figure out the best way to coordinate benefits.

Review your plans and decide which benefit plan to submit to first and then whatever portion left unpaid may be claimed through the second insurer. In some instances, your primary insurer may not cover a medication or other treatment, but the secondary insurer will. Also some plans have annual maximums for claims. You may also be able to claim the amount not covered by one insurer from the other.

The short answer: when a pharmacist dispenses a drug that contains the same active medical ingredients as the brand name drug. Generics are substituted as they are less expensive.

When drug patents expire, other manufacturers can produce generic versions of those drugs — typically at reduced price. Increasingly, benefit plans (public and private) require the pharmacist to provide the least expensive drug, regardless of what was written on your prescription.

If the generic product has not worked for you or are unable to tolerate it your physician can indicate “no substitution” on your prescription and the cost of the brand name drug may be covered by your plan. The company may require your physician to provide additional medical evidence in this case.

If your private health insurance plan doesn’t cover your needed treatment, consider the following:

  • Gather necessary information and call the insurance company’s benefits department to confirm that they do not cover the treatment. Ask why they won’t cover it. If needed, have your physician contact the insurance company. (HINT: have your benefits policy number, employer’s name/policy number, if the treatment is a medication, the drug identification number (DIN) and your physician’s phone number).
  • Let the human resources manager at your workplace (or union or association representative) know what the insurance company told you and explain that your physician considers this treatment vital to your health and well-being.
  • Determine if the insurance company has decided not to cover this particular treatment or if it is specifically excluded by the plan your employer, union or association (plan sponsor) has purchased.
  • If the latter, a plan sponsor has the option of making an exception. you can advocate with your plan sponsor to have your treatment covered.
  • If it is the decision of the insurance company, have your physician write a letter of appeal, giving the reasons why you need this treatment. If the appeal is rejected you can contact the insurance company’s ombudsman to file a complaint and request reversal of their decision.
  • If you are part of a patient support group or discussion boards or chat rooms, ask if others have had a similar experience.

Other Options

Compassionate programs to help with the cost of prescription drugs exist to help Canadians who have high prescription costs compared to their household income. The eligibility criteria vary across these plans. Usually these programs will provide support for the drugs that are listed on that province or territory’s formulary. For links to your ministry or department of health, review the “My Public Coverage Options” tab above to access the public coverage options in your province.

Exceptional Access Program (EAP) or Special Access Program (SAP) helps people access drugs that aren’t currently listed for coverage on a formulary, or for which there are no alternatives. To apply for the EAP/SAP, your physician must submit a request that documents your medical information and a clinical rationale for requesting the unlisted drug, with reasons why a covered drug is not suitable.

It is worth checking with your doctor about possible programs with the company that makes the medication that you need. Some companies provide assistance to help offset or reduce your out-of-pocket costs not covered by your public or private drug plan.

This is typically for expensive drugs, for which out-of-pocket costs could present a significant financial challenge for you. Claims are processed through a third party such as an organization that administers the drug.

If you are unsure about insurance coverage, your prescribing physician, pharmacist or local hospital may be able to direct you to a medication reimbursement specialist. These specialists are situated in various hospitals and pharmacies across the country. Their role is to help you find ways to pay for your medications. They can:

  • Review your private insurance plan with you, if you have one, to see what kind of coverage you have
  • Assist with insurance navigations and appeals both with public and private insurers
  • Help you apply to patient assistance programs
  • Help you apply to provincial or territorial compassionate programs and speed up approval of the application
  • Help you and the prescribing physician fill out insurance forms

In some cases, a medication reimbursement specialist can help find coverage for drugs that are not currently covered by:

  • Appealing to your provincial or territorial  Exceptional Access Program
  • Appealing to private insurance
  • Access compassionate drug supply

Source: Princess Margaret Hospital Lunch and Learn Drug Coverage 101

If you take expensive medications, like a biologic, a patient support program may be made available. It can help you find funding for the drug. Check with your prescribing physician; he or she should know if such a program exists for your drug and how to get information.

If you rely on a public health insurance plan but find that a treatment you need is not covered, there are steps you can take. You can advocate for coverage for treatment for yourself, a friend, a relative, or a child. The Arthritis Society self-advocacy guide provides tools to get you started.

Disclaimer: This resource is meant solely to be a guide for information. While Arthritis Society Canada strives to provide up to date and comprehensive information, these types of services vary from province to province and times from region to region and community to community. Users are requested to check all sources from provincial/territorial, regional and community levels, as well as public, private and not-for-profit/charitable resources. This guide is not and cannot be a complete listing of all sources of services available.

Once you and your healthcare professional have agreed on your treatment plan, consider how those treatments will be paid. As you may already know, certain arthritis medications are very expensive and questions of will this cost be covered and by whom are important.