Public Drug Plan Designs, 2019/20

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This document provides a summary of the NPDUIS public plan designs in 2019/20, as detailed in the Plan Information Document published by the Canadian Institute for Health Information.^{Footnote 1}

British Columbia

Plans/Eligibility

British Columbia has a universal program with a variety of beneficiary groups and sub-plans: the Fair PharmaCare plan provides regular assistance to residents born in 1940 or later, with enhanced assistance provided to residents who are part of a family with at least one spouse born in 1939 or earlier; permanent residents of licensed residential care facilities; recipients of income assistance and children and youth in care; individuals with cystic fibrosis who are registered with a provincial cystic fibrosis clinic; severely handicapped children 18 years and under; psychiatric medication for individuals registered by a Mental Health Services Centre; medication management services provided by pharmacies such as publicly funded vaccinations and review of a patient’s medication; palliative care at home; patients enrolled at BC Centre for Excellence in HIV/AIDS; and a smoking cessation program. The BC Smoking Cessation Program’s selection of eligible non-prescription nicotine replacement therapy (NRT) products expands to include specific lozenges and inhalers. Effective October 1, 2017, PharmaCare Plan W offers 100% coverage of eligible benefits to the First Nations Health Authority (FNHA) clients who were previously covered by Health Canada’s Non-Insured Health Benefits (NIHB) Program.

PharmaCare’s Low Cost Alternative program helps control the cost of prescription drugs. When the same drug is made and sold by more than one manufacturer, PharmaCare covers the less costly version, the low-cost alternative.

Cost Sharing

British Columbia has income-based annual deductibles for its Fair PharmaCare and enhanced Fair PharmaCare assistance programs (see tables below). There are no deductibles for other programs/plans. After deductibles are met, there are co-payments of 30% of the prescription drug costs for the Fair PharmaCare program and 25% for the enhanced program.

Effective January 1, 2019: Families with net annual incomes between $15,000 and $30,000 are no longer required to pay a deductible. Copayments are eliminated for families with a net income up to $13,750. The maximum copayment contribution is lowered for regular assistance families with net incomes up to $45,000.

Alberta

Plans/Eligibility

Alberta has a number of government-sponsored health benefits programs for Albertans registered under the Alberta Health Care Insurance Plan. Coverage for Seniors is a premium-free plan available to Albertans 65 years of age and older; effective March 1, 2020, this plan no longer covers family members or dependents under 65 years of age. Non-Group Coverage is a premium-based plan available to Albertans under 65 years of age and their dependents. Palliative Coverage is available for Albertans diagnosed as palliative and who are being treated at home or a hospice where access to publicly funded health services are not included.

Health benefits programs provided through low-income plans are consolidated within the Ministry of Health, and include drug benefits for recipients being assisted under Income Support, Adult Health Benefit, Child Health Benefit, Assured Income for the Severely Handicapped, Child Intervention Services, and Family Supports for Children With Disabilities. Information for these plans is not submitted to NPDUIS.

There are several other programs, including the Public Health Activities Program (e.g. Women’s Choice Program – access to Mifegymiso, Influenza Immunization Program, HIV PrEP Program), the Rare Disease Drug Program, the Insulin Pump Therapy Program, the RAPID Program, the Disease Control and Prevention Program, the Outpatient Cancer Drug Program and the Specialized High Cost Drug Program (includes funding for transplant drugs and drugs for the treatment of HIV/AIDS, as well as several other drug costs). Information from these programs is also not submitted to NPDUIS.

Cost Sharing

Alberta sets co-payments at 30% of the prescription to a maximum of $25 for seniors and non-group beneficiaries. Between March 1, 2020, and June 15, 2020, the maximum co-payment of $25 was temporarily adjusted to $8. Effective March 1, 2020, there are no co-payments for palliative patients . Premiums for non-group beneficiaries are $118.00/month for families and $63.50/month for singles. Subsidized premiums for non-group beneficiaries are offered based on income as follows: $82.60/month for families and $44.45/month for singles.

Saskatchewan

Plans/Eligibility

The Saskatchewan provincial government has several drug plan programs for residents who are not covered under federal government programs. The Children’s Drug Plan Program provides coverage for prescription drugs listed on the Saskatchewan Formulary and those approved under Exception Drug Status for children age 14 and under. The Seniors’ Drug Plan Program provides coverage for prescription drugs listed on the Saskatchewan Formulary and those approved under Exception Drug Status. Saskatchewan residents over 65 with income less than the Provincial Age Tax Credit are eligible for coverage. Income Supplements Program provides coverage for residents qualifying for the federal Guaranteed Income Supplement (GIS) and the Saskatchewan Seniors Income Plan (SIP). The Special Support Program is an income-tested program that helps residents with high drug costs in relation to their income. Eligible applicants receive a deductible and/or a co-payment on their prescription drugs for each calendar year.
The Palliative Care Program covers the costs of prescription drugs for palliative care patients who are in the late stages of terminal illnesses with a life expectancy measured in months, who have no appropriate treatment options to cure the illness or prolong life, and who require care to maintain quality of life. The Saskatchewan Aids to Independent Living (SAIL) Program assists people with physical disabilities to achieve a more active and independent lifestyle and assists people in the management of certain chronic health conditions. The program provides a basic level of coverage for disability-related equipment, devices, products, and supplies in order to achieve the best possible care, experience, and health for beneficiaries. The Supplementary Health Benefit Program provides drug coverage to residents enrolled in a variety of provincial income support programs. Eligibility is determined by Saskatchewan’s Ministry of Social Services. The Family Health Benefits Program provides a range of health benefits, including drug coverage, to low-income working families who either meet the standards of an income test or are receiving the Saskatchewan Employment Supplement or the Saskatchewan Rental Housing Supplement. Emergency Assistance for Prescription Drugs provides one-time assistance for residents who require immediate treatment with benefit prescription drugs and are unable to cover their share of the cost. The resident is required to submit a completed Special Support Program application to the Drug Plan in order to receive future assistance. Claims for Formulary and Exception Drug Status drugs are submitted to NPDUIS, while drugs covered under special programs such as the Saskatchewan Cancer Agency are not.

Cost Sharing

Manitoba

Plans/Eligibility

Manitoba Pharmacare provides drug cost assistance to eligible Manitobans who do not have coverage under a federal or other provincial program. Pharmacare is income-based, which means a deductible is calculated based on the total adjusted family income. It covers all provincial residents who are eligible for benefits under the Prescription Drugs Cost Assistance Act and includes residents as defined by the Health Services Insurance Act. To be eligible, the person must be a member of a family that has spent more on specified drugs in a benefit year than the allowed deductible amount.

Other sub-plans cover those who receive benefits from the Employment and Income Assistance Program; residents in personal care homes who receive benefits from the Personal Care Home Drug Program; individuals who are terminally ill and wish to remain at home from the Palliative Care Drug Program; and individuals requiring out-patient cancer treatment with eligible oral cancer and specific supportive drugs from the Home Cancer Drug Program. Drug products approved for coverage under the Exception Drug Status (EDS) Program, listed under Part 3 of the Manitoba Drug Formulary, are not submitted to NPDUIS.

Cost Sharing

Manitoba has an annual deductible based on total family income, with a minimum deductible of $100. The deductible increased to between 3.17% and 7.15% for 2019/2020.

Ontario

Plans/Eligibility

The Ontario Drug Benefit (ODB) Program covers Ontario residents that are 65 and older; residents of long-term care homes and homes for special care; recipients of professional home services; recipients of social assistance; and recipients under the Trillium Drug Program (TDP), which provides drug benefits for Ontario residents who have high drug costs in relation to their household income. The OHIP+ Program, effective January 1, 2018, extended the ODB Program to cover OHIP-insured children and youth age 24 and younger; on April 1, 2019, the program was changed to cover only those age 24 and younger who do not have coverage through a private plan. The Special Drugs Program covers certain outpatient drugs used to treat specific diseases. The New Drug Funding Program covers drug benefits for intravenous cancer drugs, administered to outpatients at hospitals and cancer care facilities.

The Exceptional Access Program covers most of the cost of various drug products that are not on the approved ODB Program list. This includes cases where drugs on the ODB list have been tried and do not work; or, where an alternative drug is not available through ODB. The Respiratory Syncytial Virus (RSV) Prophylaxis for High-Risk Infants Program covers the full cost of the drug palivizumab used to prevent a serious lower respiratory tract infection in certain high-risk infants. The Visudyne Program covers the full cost of the drug verteporfin used to slow the advance of age-related macular degeneration. The Inherited Metabolic Diseases (IMD) Program covers the full cost of certain outpatient drugs, supplements, and specialty foods used to treat metabolic disorders.

Cost Sharing

The Ontario Drug Benefit (ODB) Program has a $100.00 annual deductible for single seniors with an annual net income equal to or greater than $19,300 and senior couples with a combined annual income equal to or greater than $32,300. Trillium Drug Program applicants must pay a quarterly or pro-rated deductible that is based on income.

ODB recipients pay up to $2.00 per prescription if they are:

• A senior single person with an annual net income of less than $19,300 or a senior couple with a combined annual net income of less than $32,300
• Receiving benefits under the Ontario Works Act or the Ontario Disability Support Program Act
• Receiving professional services under the Home Care Program, Ontario Works, or Ontario Disability Support Program
• Residents of long-term care facilities and homes for special care
• Eligible under the Trillium Drug Program (once their quarterly deductible is reached)

ODB recipients pay up to $6.11 toward the dispensing fee per prescription once they reach their $100.00 annual deductible if they are:

• A senior single person with an annual net income equal to or greater than $19,300
• A senior couple with a combined annual net income equal to or greater than $32,300

A co-payment of up to $2.83 is made for each prescription dispensed from an outpatient hospital pharmacy.

All ODB Program recipients age 24 and younger eligible for benefits through the ODB Program have no deductible and no copayments.

Residents living in a long-term care home have no deductible. Effective January 1, 2020, under a new long-term care (LTC) capitation funding model, no copayments may be charged to a resident of an LTC home for dispensing an eligible Ontario Drug Benefit (ODB) drug product or listed substance.

Changes to the “no substitution” provisions require that patients try two or more generics (and experience two documented adverse reactions to the two formulations) prior to having a brand-name product paid for by the public plan.

Quebec^{Footnote 2}

Plans/Eligibility

The Public Prescription Drug Insurance Plan provides coverage to Quebec residents without access to a private plan through their employment or profession, spouse, or parents if they are a student or child; persons age 65 and older who have not joined a private plan; recipients of last-resort financial assistance; and certain other holders of claim slips (carnet de réclamation).

Quebec residents age 65 and older are automatically registered for the public plan. If they remain eligible for a private plan offering basic prescription drug coverage, they may decide to be insured only by the public plan, administered by the Régie de l’assurance maladie du Québec (RAMQ); by the public plan (first payer) and by a private plan offering supplemental coverage (second payer); or only by a private plan offering at least the basic coverage.

Cost Sharing

Cost sharing in Quebec ranges depending on income and other factors.

The Public Prescription Drug Insurance Plan has a net family income–based premium, ranging from $0 to $636 per person. Beneficiaries copay 37% of the prescription cost minus the deductible, where applicable. The monthly deductible is $21.75 per person paid through the first purchases of the month.

No premium, copayment/co-insurance, or deductible is required for holders of claim slips (carnet de réclamation), children of persons covered under the public plan, recipients with a functional impairment, and seniors receiving more than 94% of the GIS.

New Brunswick

Plans/Eligibility

The New Brunswick Prescription Drug Program (NBPDP) provides coverage to low-income seniors, clients of the Department of Social Development, nursing home residents and individuals with certain medical conditions (cystic fibrosis, growth hormone deficiency, HIV/AIDS, multiple sclerosis, organ transplant recipients). The New Brunswick Drug Plan provides coverage for uninsured residents. The Medavie Blue Cross Seniors’ Prescription Drug Program provides coverage for uninsured seniors. The Medical Abortion Program offers universal coverage for the cost of drug products used. The New Brunswick Drugs for Rare Diseases Plan offers coverage to residents who have one of a specific list of rare diseases and meet the clinical criteria for the drug requested; data for this plan is currently not submitted to NPDUIS.

Cost Sharing

Premiums and co-payments vary depending on the plan.

Nova Scotia

Plans/Eligibility

Nova Scotia provides assistance to residents through various programs with the cost of drugs and devices listed as benefits in the Nova Scotia Formulary, as well as with the cost for some services to which a level of coverage applies under a particular program.

The Family Pharmacare Program provides assistance with prescription drug coverage for residents of Nova Scotia with a valid Nova Scotia health card. Other programs/plans include Drug Assistance for Cancer Patients for families with a gross income no greater than $25,500 that do not have drug coverage under any other program, except Family Pharmacare; the Diabetes Assistance Program, which is now closed to new enrollees; and the Seniors’ Pharmacare Program, which is available for residents who are age 65 or older. The Insulin Pump Program helps cover the cost of both insulin pumps and pump supplies for patients with type 1 diabetes who are age 25 and younger. The Palliative Care Drug Program covers the cost of drugs needed for end-of-life care at home, including those used to manage symptoms associated with end-of-life-care beyond the patient’s regular coverage. The list of drugs – Palliative Care Drug Program Formulary – is based on the pan-Canadian Gold Standards for Palliative Care. The Take-Home Cancer Drug Fund, launched in February 2018, helps patients who face high costs for take-home cancer drugs. Claims dispensed through the Department of Community Services programs for residents on income assistance are not submitted to NPDUIS. The Exception Drug Fund provides coverage for certain high-cost outpatient medications dispensed by the Nova Scotia Health Authority and the IWK Health Centre under specific circumstances; data for this plan is not currently submitted to NPDUIS.

Cost Sharing

The Seniors’ Pharmacare Program in Nova Scotia has a maximum annual premium of $424.00. There is no premium for single seniors with an income lower than $22,986 or for seniors who are married and have a joint income less than $26,817. Seniors receiving the Guaranteed Income Supplement are also exempt from premiums. Other senior beneficiaries may have a reduced premium: for singles with an income between $22,986 and $35,000, and those who were married with a joint income between $26,817 and $40,000.

Nova Scotia’s Family Pharmacare and Diabetes Assistance programs have annual maximum deductibles based on sliding-scale percentages in relation to family size and income. The Nova Scotia Family Pharmacare program also has an annual maximum co-payment based on family size and income.

Prince Edward Island

Plans/Eligibility

Prince Edward Island Pharmacare is the payer of last resort for public drug programs delivered through retail pharmacies. Residents using a public drug program who are also members of private insurance programs must bill their private insurance first and Pharmacare second. The public drug programs are listed in the table below.

Patients who qualify for programs delivered through Provincial Pharmacy (a centralized provincial dispensary) are entitled to eligible medications provided in those programs, at no cost to the patient.

As of January, 2019, a new Ostomy Supplies Program provides financial assistance for those living with a permanent ostomy. Coverage ranges from 60% to 90% of eligible expenses, dependent on income.

Cost Sharing

Prince Edward Island has co-payments per prescription that vary for each program/plan and some medications.

Newfoundland and Labrador

Plans/Eligibility

The Newfoundland and Labrador Prescription Drug Program (NLPDP) provides financial assistance for the purchase of eligible prescription medications for those who reside in the province. The program covers a variety of drugs that require a prescription, plus a small number of over-the-counter items that do not legally require a prescription. However, these products must be prescribed to be covered under NLPDP plans. In addition, some drugs are covered under special authorization, meaning that certain medical criteria must be met.

There are five main plans under the NLPDP program. The 65Plus Plan covers residents 65 years or older who receive old age security benefits and the Guaranteed Income Supplement. This plan also contains a sub-program entitled The Ostomy Subsidy Program. The Foundation Plan covers persons and families in receipt of Income Support benefits through the Department of Advanced Education, Skills, and Labor; children in care of the Regional Health Authorities or the Department of Child, Youth, and Family Services, as the case may be; individuals involved with Community Youth Corrections; persons in receipt of community supports; and persons who are subsidized residents in Long Term Care Homes and Personal Care Homes. The Access Plan covers residents with a low income determined by family net income level. The Assurance Plan covers residents with the financial burden of eligible high drug costs. Finally, The Select Needs Plan covers residents who have been diagnosed with cystic fibrosis and residents aged 18 years or younger with growth hormone deficiency.

Cost Sharing

Both The Foundation Plan and The Select Needs Plan provide 100% coverage of eligible prescription drugs. The maximum dispensing fee under The 65Plus Plan is $6.00 per prescription. Those who qualify for a drug card under The 65Plus Plan also qualify for The Ostomy Subsidy Program which reimburses 75% of the retail cost of benefit ostomy items; the beneficiary is responsible for the remaining 25% of costs. The Assurance Plan provides prescription drug coverage to individuals/families where eligible drug costs exceed: (1) 5.0% of net income for those who earn below $40,000; (2) 7.5% of net income for those who earn from $40,000 to under $75,000; and (3) 10.0% of net income for those who earn from $75,000 to under $150,000. The Access Plan’s co-payment structure is based on the annual income and family status as shown in the table below.

Yukon

Plans/Eligibility

For residents not covered through a federal or territorial drug program, such as First Nations and Inuit Health Benefits and Veterans Affairs Canada, Yukon has a Pharmacare program for seniors age 65 and older (and seniors’ spouses age 60 and older) registered with Yukon Health Care Insurance Plan, which may also include clients receiving palliative care; a Children’s Drug and Optical Program for children under 19 from low-income families; a Chronic Disease Program for residents who have a chronic disease or a serious functional disability as provided under the Chronic Disease and Disability Benefits Regulations, which may also include clients receiving palliative care; and a Palliative Care Program, which provides enhanced coverage for patients registered in the Chronic Disease or Pharmacare program for whom life expectancy is measured in months. Residents with private or group insurance plans must submit claims to those plans first and will then be eligible for top-up benefits.

Cost Sharing

Yukon has a deductible of up to $250 per child per year for the Children’s Drug and Optical Program, depending on income, to a maximum beneficiary contribution of $500 per family per year. There is also a $250 per person per year deductible for the Chronic Disease Program, which also may be waived or reduced depending on income, to a maximum beneficiary contribution of $500 per family per year.

Non-Insured Health Benefits (NIHB)

Plans/Eligibility

The Non-Insured Health Benefits Program provides registered First Nations and recognized Inuit with coverage for prescription drugs and some over-the-counter products listed on the NIHB Drug Benefit List (DBL). To be eligible, an individual must be a resident of Canada and a registered First Nations according to the Indian Act; an Inuk recognized by one of the Inuit Land Claim organizations; or an infant of up to 18 months whose parent is an eligible recipient. Those individuals who are otherwise covered under a separate agreement (e.g., a self-government agreement) are not eligible for coverage.

During the COVID-19 (coronavirus) pandemic, the NIHB Program temporarily provides coverage to unregistered infants under the age of 24 months that have an eligible parent.

Cost Sharing

Recipients of the NIHB program do not pay deductibles or co-payments.