Insurance and Drug Coverage
Tips on Advocating for Drug Coverage
“I went through a period of time where I was employed, and under my work benefit program I could get my medication – no problem. I was later self-employed, and I was paying about $500 every couple months. This was incredibly burdensome.” – Naaz Bashir
Medication for Crohn’s and colitis can be expensive. For the roughly 40% of Canadians that do not have private drug coverage through employer-paid insurance plans, cost can be a serious barrier to accessing the medications they need.
Many individuals are faced with this significant challenge. For seniors and those with low incomes, many provinces offer health and drug plans that provide varying levels of support. There are roughly 11 million Canadians that receive drug coverage through one of 19 provincial and federal public drug programs. Each province has designed its coverage program around different needs. The British Columbia drug program uses an income-based deductible to calculate support. Quebec is insurance based, where residents must be covered by either private insurance or the public plan. In Ontario coverage is predominantly age based, with coverage provided for people above the age of 65.
Even if you are eligible for coverage under one of the public plans, you may still be required to pay some amount in the form of either a co-payment (a flat fee that you pay with each prescription); co-insurance (a percentage that you pay with each prescription); deductible (a certain amount that you pay with each prescription until you reach a maximum amount, at which time the public plan pays 100%); and/or a premium (a payment you make whether or not you receive a prescription).
Purchasing your own insurance
A growing number of Canadians do not fall within either of the above mentioned scenarios. Freelancers, contract workers, the self-employed and many more do not enjoy the benefit of employer-paid health insurance. However, these individuals may earn too much to qualify for provincial supports – leaving them all on their own when it comes to health insurance.
In this case, individuals must either pay out-of-pocket for medication or purchase their own private insurance product. For individuals with chronic conditions such as Crohn’s disease or ulcerative colitis, this can pose great challenges. Insurance companies will often attach higher premiums or even decline applications for people living with chronic illnesses. Below is a list of tips to help you apply for health, life or disability insurance:
- Re-apply for insurance when in remission. Your insurability improves after periods of good health.
- Have regular medical check-ups. People under regular medical supervision are rated more favourably.
- Try to find or keep a job that offers group insurance. An applicant's ability to maintain the same job is also an important factor in obtaining individual insurance.
- “Shop around" and try to identify insurance companies who have an understanding of inflammatory bowel disease (IBD). Some companies - particularly those familiar with IBD - may offer lower premiums.
- Ask your doctor to write a letter to the insurance company about your condition and request him/her to interact directly with the company's medical director. You are more likely to be accepted for insurance if your physician helps the medical director evaluate the risk.
Read our Talk About Guts article “You are Insurable!” from July 2016 about an insider's perspective on the insurance industry and getting your own coverage.
Advocate for yourself
Once you have insurance, either through your employer or purchased privately, issues can still arise. Here are a few tips to guide you through the most common scenarios:
About group benefits
If you are employed and have access to benefits, be sure to understand the details of your employer’s group benefit package. Talk to your human resources department and learn about what you can expect if you make a claim. When leaving your employer, your benefits will also terminate. If you are not going to a new employer you will need to consider obtaining individual private insurance.
If your claim is rejected
Once you have insurance, there may be times when your claim is rejected. First of all, be sure of your rights under your policy. Check to make sure that you have not made a claim for something for which you are not entitled.
If you think you are entitled, don’t let the first or even the second rejection stop you. Persistence is key. Use your policy’s appeals process and be sure that your physician is supplying the necessary supporting documentation. This may be a case of insufficient or inadvertent information that is causing the rejection.
Contact the insurance company’s ombudsman or complaints officer. He or she is there to assist consumers with complaints. If you are still not satisfied, request a letter from your insurance company, stating their final position and supporting documentation. You can then use the free, national services of the impartial OmbudService for Life and Health Insurance (OLHI) to help you with your claim. Be sure to keep a record of all your correspondence and medical information so that the ombudsman can conduct a thorough review of your case.
Recruit the assistance of your human resources department if you are a member of your employer’s group benefit plan. Staff in that department should be able to help you with your claim and in some circumstances, the employer has enough persuasive power to help overturn the rejection or get certain drugs added to an approved formulary list.
I’m insured but my drug is not covered
If your employer has excluded certain drugs from the approved list of medications for reimbursement, you may wish to disclose your condition to your HR manager. Describe your condition and ask that your employer either update the drug plan to include your medication as part of the plan or make an exception. If not covered, ask your health benefits manager (often the HR manager) why they decided not to cover the drug. There may be an alternative coverage that you can apply for. Ask if there is an opportunity to apply for interim coverage.
It is in the best fiscal interests of an organization to keep their staff healthy and on the job. It is important that you document all of your communication and exchanges with your plan sponsor and/or insurer.
Supplementing private insurance
Some individuals may wish to purchase private coverage or supplement existing coverage they already have. You may want to consider working with an insurance agent, especially one who is familiar with and specializes in chronic conditions or illnesses. Insurance premiums remain the same whether you purchase your policy by yourself or through an agent. It is important that insurance applications are completed accurately and a licensed agent can make sure that medical questions are answered completely and in detail.
Managing healthcare for yourself or a loved one’s can be a daunting task. Persistence, communication, documentation and information are key to advocating for appropriate care.
We work hard to advocate for better access to medications for all Canadians. Click here to read our 2014 Biologic Coverage for Inflammatory Bowel Disease in Canada Report Card. To learn more about our advocacy efforts click here.
Access the Health Charities Coalition of Canada (HCCC) "How To" Health Guide for a comprehensive view of how drugs are covered across Canada