A private drug plan is a group insurance or benefits plan covering prescription drugs. It is managed by a private company, unlike the public prescription drug insurance plan administered by the RAMQ. Any person permanently established in Quebec and any minor child who stays there for more than six months must be covered by prescription drug insurance according to the Act respecting prescription drug insurance.
Access to a private plan and obligations
If you are permanently established in Quebec, you must join a private plan, at least for prescription drug coverage, if you have access to it and you are under 65 years of age. In addition, you must ensure your children and your spouse if another private plan does not already insure them. You must do the same for any person with a functional impairment who lives in your home. You can access a personal plan in different ways:
- In the context of your job or profession (by your employer or your professional group: union, association, or order)
- Through your spouse
- Through your parents
If you do not have access to a private plan, you must register for the public prescription drug insurance plan.
If you are staying in Quebec, only your children under 18 must be covered by drug insurance if they are present in Quebec for more than six months. The public drug insurance plan must cover them unless your private coinsurance already covers them.
Minimum coverage conditions
All private insurance plans are required to provide basic drug coverage. This means that the private insurance must at least include the medications covered by the public agenda, those that appear on the list of medicines. Covered drugs include exception medications and those covered for an exceptional patient with a severe medical condition.
Some private plans cover drugs only. Others also cover additional services, such as consultation with health professionals (for example, physiotherapists and chiropractors), vision care, or dental care. Thus, the offer of each private plan may vary, except for the basic coverage for drugs.
Costs associated with the private plan
You generally pay a premium to be insured by a private plan. In addition, you contribute to the payment of your drugs covered by the program up to a maximum amount. Your insurer also pays its share of the cost of medication. He can reimburse you in different ways.
Individuals covered by a private plan generally have to pay a premium whether or not they buy drugs. This premium is negotiated between the insurer and the employer (or the professional association). The Act respecting prescription drug insurance obliges the employer to deduct the compensation from the pay of each insured person and pay this amount to the insurer.
Contribution to the payment of medication
Payment for drugs covered by pharmacies generally includes a contribution on your part, as with the public plan. This contribution is often composed of the following elements:
- Deductible: Fixed amount paid on first purchases. In the case of private plans, the deductible is generally annual. Some private plans have no deductible.
- Coinsurance: Percentage of the drug price that you pay. It applies once the deductible is paid.
The law on prescription drug insurance This link will open a new window. And sets a maximum annual contribution, a ceiling. The ultimate set by a private plan must be equal to or lower than what is provided for in the law. Once the maximum is reached, the insurer pays all costs for covered drugs for the rest of the year. You continue to pay at the pharmacy only for drugs not covered and for any excess depending on your contract.
Ways to get reimbursement from the insurer
You should find out from your insurer how it reimburses you for its share of the cost of your medication. You can be refunded at the time of purchase or after purchase, with or without action.
At the time of your purchase
You only pay your contribution to the cost of the drug when you buy it at the pharmacy. Your insurer then pays its share to the pharmacist.
After your purchase without procedure
You pay the total cost of the drug at the pharmacy. The pharmacist submits a reimbursement request to your insurer. You then receive the reimbursement, for example, by check or direct deposit.