Throughout this section, we will shed some light on the private and public Prescription drug insurance plans (Régime général d'assurance médicaments, or RGAM).
Prescription drug insurance plan (Régime général d’assurance médicaments, or RGAM)
The 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.
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 your 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. For medications available through an exceptional access program, private insurers must provide coverage equivalent to the Régie’s public prescription drug plan.
If you have questions about your private prescription insurance plan or have reason to believe that:
- Your insurer is not covering the proper amount.
- Your co-payment is not being calculated correctly.
- Your maximum annual contribution is higher than the amount specified by the Régie.
- Your insurance plan restricts your coverage for medications that are on the Régie’s official List of Medications.
- Your freedom to choose a pharmacist is being restricted.
You should contact the Régie de l’assurance maladie du Québec and the OmbudService for Life & Health Insurance. These organizations can provide useful guidance relating to the application of the Act Respecting Prescription Drug Insurance by private insurers and private plans. You can also file a complaint with either organization.
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 you are covered by the public prescription drug insurance plan, your pharmacist sends your claim to the Régie which will then determine what you must pay for your 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.
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 with respect to exceptional medications. In this case, private insurers must provide coverage equivalent to the Régie’s public prescription drug plan.
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. You may also visit www.ramq.gouv.qc.ca
* All amounts and percentages mentioned in this section are those in effect as of July 1, 2020.