Since the 19th century, Earth’s population has grown exponentially, creating a need for effective medicine. Many diseases are communicable, while others can be spontaneous, environmental, or genetic. Some ailments can be cured with rest and minimal intervention, but others rely on medication.

Thankfully, health insurance plans increase access to necessary treatment for many Canadians. Many plans will cover a portion of the cost for most medications, but there are many others that may not be covered.

What Types of Medication Are There?

In Canada, medications can be sold only if they are a certain “schedule” or category. According to the National Association of Pharmacy Regulatory Authorities (NAPRA) website, medications are reviewed and assigned a schedule depending on their ingredients.

This list indicates whether a drug is considered a narcotic, or if it could potentially lead to criminal prosecution if it is in your possession. It also specifies whether or not the drug would require a prescription.

What Will My Plan Cover?

Most health insurance companies will cover any drug that requires a prescription, with some restrictions. When in doubt, you can ask an insurance representative. Be aware that there may be some requirements before you get reimbursed.

For example, if your doctor gives you a prescription for an opioid such as hydromorphone, you may be limited to a 30-day supply. If your account shows prolonged, excessive claims, they may ask for a note from your doctor explaining your condition and why the dosage changed.

Over the counter (OTC) drugs are also common purchases, but are usually not covered. Even if your doctor gives you a prescription for an OTC drug, your plan will not pay for it. However, if you are a resident of Quebecyou may have coverage through the provincial health plan, depending on the drug.

If you are in the hospital, drugs you receive are not covered by your health insurance. Those medications are covered under your provincial plan.

Fertility drugs are sometimes covered by group plans, but are restricted to a dollar maximum, or will only cover a certain number of cycles of drugs.

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Allergy shots may be covered if administered by your doctor, but not all plans will cover these. They would need to list the Drug Identification Number (DIN) in order to be eligible. Similarly, vaccines for travel purposes may or may not be covered. Your regular flu shots and other vaccines are paid under your provincial plan, depending on where you live.

Do You Live in Ontario and Have Kids?

If you live in Ontario, the Ontario Health Insurance Plan (OHIP+) will pay for prescription drugs for all residents age 24and under. This is a new program in the province as of January 2018, which gives children and young adults access to some necessary medications, though there are many drugs that are not eligible, either.

If your child’s prescription is not payable under the OHIP+ plan, it may be covered under your personal health insurance.

Find Out For Sure

If you are given a prescription for a certain medication and are uncertain if it is covered, call our office and we can look the information up for you. We will need the DIN of the drug to look it up and see if it is covered. You can also try checking with a pharmacist (have your drug card on hand). They should be able to see on your file if it is covered.

If the program will not pay for the drug, the pharmacist will get a message telling them why it is not being paid.

Call Us

If you would like to find out more about what your health insurance plan will pay in terms of prescription drugs, give us a call and we can help you understand your benefits. If you wish to perhaps upgrade your plan and get more coverage, we can help you do that too! Be sure to disclose any pre-existing conditions you may have as it may affect your coverage. We do have plans that may accept you but you will be required to fill out a questionnaire.

We care about your health and want you to know what your options are. Prescription medication is an important part of many people’s lives. Having an insurance plan that helps pay for the cost is a great thing to have. Before you know it, we’ve got you covered!