Access to Medication

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.