MS: Medication Reimbursement - MedBroadcast.com

Introduction to MS medication reimbursement

What is medication reimbursement?

Medication reimbursement is the process of having some or all of your medication costs paid for by an outside source, such as an insurance company, government, or other program. Getting reimbursement for your MS medications can help reduce your expenses and make it easier to get access to the treatments you need.

How are MS medications reimbursed in Canada?

There are three main ways that you can get reimbursement for your MS medication.

Government coverage: Drug coverage is usually handled by the provincial government, although there are federal government drug programs that cover some people, including certain government employees, members of the Canadian Forces, refugees, and inmates in federal prisons.

Most provincial drug plans cover the majority of MS disease-modifying medications for people who are eligible for these plans. The exact coverage, what you need to qualify, and how much you will need to pay out of your own pocket differs by province, and it often depends on your family's income. Some provinces also offer special coverage for people facing high medication costs not covered by private plans. For more information, contact the MS Society of Canada, which can direct you to the appropriate information source for your province.

Private insurance: Most Canadians have some form of private insurance, either through their employer or through drug insurance plans that they have purchased themselves. Private drug insurance is offered by a variety of insurance companies in Canada, and many different plans are available.

Some plans pay all of the cost of the medication, but many plans require the person to pay some of the costs themselves, either as a small percentage of the total costs (co-payments, or simply co-pays), as a fee with each prescription (co-pays), or up to a fixed maximum amount each year (deductibles). The exact details depend on the plan.

Although many private plans cover MS medications, most plans also limit the total amount that they will pay for medications in a given year (caps), and this amount is often less that the total yearly cost of disease-modifying medications for MS. If this is the case, you may need to apply for additional drug coverage through a government plan or pay for the costs out of your own pocket. Many provinces have plans that help pay for costs not covered by private plans.

Some private plans provide you with a drug card that allows your pharmacy to bill your insurance company directly for the cost of the medication. Other plans require you to pay for the medication up front, and then submit a claim form to have the costs reimbursed later.

Out-of-pocket: You can pay the costs yourself out of your own pocket. However, given the fact that other insurance options are available, it's a good idea to see whether you may be eligible for private or government insurance coverage before paying all of the costs yourself. For more information, speak to your doctor, call your local MS society, or contact the manufacturer of your MS medication.

Other sources of medication reimbursement: If you are in the hospital, the costs of any medications you may need during your hospital stay will be covered by the hospital's budget. However, this only lasts until you leave the hospital.

In some cases, you may be eligible for a compassionate program from the pharmaceutical company that makes your MS medication. These programs may cover the cost of your MS medication while you are waiting for your private or government coverage to come through.

For more information on MS medication reimbursement, see "Finding the reimbursement you need."

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Reimbursement: speaking the language

Medication Management

Baffled by some of the terms you've seen or heard while looking into medication reimbursement? Here's a quick guide to understanding some common medication reimbursement terms. Many drug insurance plans will use these words, and understanding them will help you get a better handle on your insurance coverage.

Terms describing payment

Cap: Many drug plans set a maximum amount that they will cover in a given time period. This maximum amount is called a cap. Some plans have yearly caps, while others have a lifetime cap.

Co-pay: Also called co-payment, this term refers to the amount of the drug costs that you will be responsible for paying. For some plans, this is a percentage, such as 10% to 20% of the total cost of the prescription. For others, it may be a fixed amount, such as $2 per prescription.

Deductible: Like car and home insurance, many drug insurance plans have a deductible, which is a fixed amount that you will need to pay before your insurance starts to help with the payments. Deductibles are usually calculated by the year, so you will have a fixed amount to pay each year before your insurance starts covering some of the costs.

Other useful terms

Coordination of benefits: People who have more than one drug insurance plan can sometimes use the second plan to pay for costs that are not covered by the first plan. This process is called coordination of benefits. For example, if you have coverage through your own workplace and through your spouse's employer, your spouse's plan may cover drug expenses that your own plan does not cover.

Coverage: A general term to describe which medications your drug insurance plan will pay for, how much you will need to pay, and how long the plan will continue to cover these medications.

DIN: DIN stands for Drug Identification Number. DINs are issued by Health Canada after it carefully reviews the product's ingredients, supporting documents, and usage instructions. Once a medication has a DIN, it can be legally sold in Canada. The DIN is found on the label of all prescription and over-the-counter drugs approved for sale in Canada. You may need to provide a product's DIN when communicating with your drug insurance company to find out about your coverage.

Formulary: This type of plan covers only a specific list of medications. The insurer (which may be a government program or an insurance company) decides which medications should be on this list by consulting experts and considering the impact that each medication may have on the plan. This list of medications is also called a formulary, and may differ between plans.

Special authorization: Some plans may cover certain medications only under limited circumstances. In these cases, your doctor will need to submit an application to your plan in order for you to be considered for coverage. This is called special authorization.

Understanding these terms will help you feel more confident when speaking to your drug insurance company. The manufacturers of many MS medications offer support programs that can help you better understand your insurance, apply for coverage, and communicate with your insurance company. To learn more, see "Finding the reimbursement you need."

Finding the reimbursement you need

Medication Management

If you have been prescribed a new medication for MS, it's time to take stock of your drug insurance. You will need to find out:

Which drug insurance plans are you eligible for? Most Canadians have some type of drug coverage, either through private plans or provincial government plans. To learn more about drug insurance plans, see "Introduction to MS medication reimbursement."
Does your drug insurance cover the medication? Contact your insurance company to find out if they cover the medication and, if so, whether there are any limits on coverage such as deductibles, co-payments, or caps (for more information on what these terms mean, see "Reimbursement: Speaking the language").
What do you need to do in order to get funding for the medication? Some plans cover medications automatically, while others require your doctor to submit an application before you can get coverage.
Does your pharmacy have the medication in stock? It's a good idea to give your pharmacy a week's notice before bringing in your prescription, as not all pharmacies carry all MS medications, and they may need to place a special order.

Many pharmaceutical companies offer special support programs that help you determine whether you are eligible for MS medication insurance coverage, understand your coverage, and apply for coverage. Some programs even arrange for home delivery of your medication.

You can also contact your local chapter of the MS Society of Canada to learn more about government-funded medication coverage available in your province.

Reimbursement FAQ

Medication Management

What can I do if I'm having trouble getting coverage?

If you're having trouble getting coverage for your MS medication from your drug insurance plan, you have a number of options. Contact your insurer to find out why they are not covering the medication. You may be able to appeal the insurance company's decision and get coverage for the medication. Speak to your doctor about submitting an appeal. You may also be eligible for other drug plans, such as provincial plans, which may cover the medication. Check with your local chapter of the MS Society of Canada for more information. Plus, many pharmaceutical companies offer special programs to help you find insurance coverage for your MS medication. For more information, contact the company that makes your MS medication.

Is it possible to use two drug insurance plans at once?

Yes. Many Canadians have drug insurance through more than one plan. For example, retirees may get drug insurance from both the government and their employer's pension plan. If you have two plans, you can use both of them to help cover the costs of your MS medication. This is called coordination of benefits. The second plan may cover some or all of the medication costs that are not covered by the first plan. This could give you a significant cost saving. However, you can never get back more than 100% of the cost of the medication.

Are private drug insurance costs tax-deductible?

In some cases, the answer is yes. Sole proprietors or partners in a business can deduct private drug insurance costs (premiums) from their taxes, provided that they meet the following criteria:

at least 50% of their income comes from their business,
their other sources of income are not greater than $10,000 per year
they are actively engaged in their business
the premiums are paid to insure a yourself or a member of your household.

Business owners and managers may also be able to deduct the cost of drug insurance from their business income if they work as an employee of the business and their benefits are similar to those offered to other employees in the business. Check with your accountant and your insurance company for more information.

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