How do drug coverage plans work?
Here are the answers to your most frequently asked questions
To learn more about how the public prescription drug insurance plan works, the way each individual’s contribution is calculated, further information on the application of the deductible or simply to sign up to the plan, contact the Régie de l’assurance maladie du Québec directly at 1 800 561 9749 or visit www.ramq.gouv.qc.ca.
The co-payment is the percentage of the cost of medications and pharmacists’ services that individuals must pay, whether they are covered by the Régie or through a private plan.
The deductible is a fixed amount that represents the portion of the pharmaceutical services and medications to be paid by the insured individual. This fixed amount must be paid by the insured person before the Régie or the private insurer pays its share. Ask your insurer about your deductible. If you are covered by a private plan, the deductible is usually an annual amount, and will vary from one insurer to another.
The premium is the amount the insured person must pay in order to be covered by the Régie’s prescription drug plan (public plan) or by a private insurance policy or benefits plan (private plan). All insured persons must pay their premium for the coverage period, even if they do not purchase any prescription medications covered during that interval. If you are covered by a private group plan, premiums are negotiated between the insurer and your employer, professional association, union, or another person responsible for negotiating the terms of the group plan. As such, the premium will differ from one insured group to another. You should learn more about the portion of your group insurance premium that applies to prescription drugs. You can ask your employer or your insurer for details.
Since the implementation of the basic prescription drug insurance plan (RGAM) in 1997, all Quebec residents have prescription drug coverage, whether public or private, which is not the case elsewhere in Canada.
When a patient is covered by the public prescription drug insurance plan, his pharmacist sends his claim to the Régie de l’assurance maladie du Québec (Régie) which will then determine what the patient must pay for his prescription. Given that the plan determines the patient’s contribution based on a variety of criteria, the amount owed to the pharmacist may vary from one person to the next.
The private plan is offered by a private company. The proposed coverage may vary from one private plan to the next, as it depends on the agreement struck between the employer and the insurance company.
A private plan is a group insurance which offers basic coverage toward the cost of medications. It is a private plan because it is offered by a private company, unlike the public plan. The proposed coverage may vary from one private plan to the next, and depends on the agreement struck between an employer and the insurance company.
However, throughout the prescription drug insurance industry, all private insurers must comply with minimum requirements as to the coverage they offer and the financial contribution they ask from those they insure.
At a minimum, private insurers are required to cover all medications appearing on the List of Medications published by the Régie, without conditions or restrictions except those that apply to exceptional medications. In this case, private insurers must provide a coverage equivalent to the Régie’s public prescription drug plan.
The Prescription drug insurance plan (RGAM) provides that, pursuant to the Act, all Quebec residents have prescription drug coverage, whether public or private.
If you are not covered by a private prescription insurance plan, you must be covered by the public prescription drug insurance plan, administered by the Régie de l’assurance maladie du Québec (RAMQ or Régie).
As for the pharmacist, he does not manage any insurance plan. His work is to ensure that the medication prescribed by your doctor is as effective as possible.