Many drugs are already covered for those aged 65 and older. But what about everyone else? The Ontario Drug Benefit Plan’s website details who is eligible and how to go about obtaining coverage.

If you are coming off a group plan, you are automatically eligible for prescription drug coverage. However, if you are not, it’s best to get your insurance BEFORE you require any prescriptions.

Costs

Some drugs are more expensive than others, but even if they cost little, they still add up as time goes by. On the other hand, there are drugs that are so expensive that an insurance plan is absolutely necessary. Drugs like Remicade, Humira, and other high-cost medications often need pre-approval, along with a doctor’s recommendation stating the patient’s diagnosis.

The same applies to insulin, which thousands of Canadians depend on to survive. Thankfully, health insurance is there to help alleviate the financial burdens that come with necessary medication.

Drug Cards

In the “olden days” you would have to pay the pharmacy and mail the receipt to the insurance company. Payment would take weeks. Nowadays, most plans provide drug cards, making it easier for you to claim through your insurance. Just present the card to the pharmacist and you’re set.

If your plan has a yearly deductible you may have that amount deducted on your first prescription fill of the year. Also, depending on the percentage your plan pays for drugs, you will be required to pay the difference.

Generic Drugs

You may get a prescription for a certain brand name drug, but sometimes the pharmacy will give you the generic equivalent. Most plans cover generics without any problems, but if your doctor feels you should have no substitutes, they will need to say so in a note to the pharmacy. It doesn’t hurt to send this note to your insurance provider as well.

Controlled Substances

Typically, you are allowed a three-month supply of medication at a time. If you have a drug card, it’s programmed to cover this amount over a three-month time period. This means you cannot buy a three-month supply today and then another next week.

It’s an unfortunate reality that drug abuse occurs and as a direct result, so does insurance abuse. Your plan has measures in place to ensure that you are not exceeding the reasonable and customary amount that has been prescribed. Controlled substances are called “Schedule IV” drugs, which are dangerous but can have therapeutic uses.

illustration of doctor's desktop with different pills, capsules, statoscope, syringe, blue folder with label 'drug abuse'

If your insurance claims are reflecting an inordinate amount of claims for opioids, your insurer may request information from your attending physician describing the condition being treated, how often you require the drug, and how long you are expected to be taking it.

This is not at all meant to embarrass or judge you; it’s meant to protect you and the insurance company itself, and the other individuals who are in the same insurance pool as you, to keep the costs down. Insurance is there to improve and enhance your health.

Insulin, Allergy Shots, Vaccines

If you have diabetes and rely on insulin, it is also included for coverage. The same goes for allergy shots and vaccines done at clinics. These types of drugs aren’t normally payable by drug card depending on where you get them, so you may need to send the receipt manually, or file your claim online.

Over the Counter (OTC) Drugs

Most plans only cover drugs that are unavailable over the counter. In some cases, however, there may be exceptions. Some creams require a medicated active ingredient in order to quality for coverage.

In Quebec, some OTC drugs are covered by the provincial plan, Régie de l’assurance maladie du Québec (RAMQ). The RAMQ website details what exactly is covered under this plan.

You don’t need to worry about the rising costs of medication if you have a plan in place. Call our office today to find out how you can get a great medical insurance plan that includes robust drug coverage!