Private Insurance

A majority of Canadians (about 60% nationally) have private insurance/third-party insurance for prescription drugs as part of the group health benefits provided by their employers. Most plans also cover the employee's family/dependants. Employers purchase these plans from insurance companies and determine the terms of the plans (what drugs are covered, how much of the cost of the drug the plan covers, etc.).

Private insurance plans generally will cover some or all of your prescription medications that are used on an outpatient basis. Even when a drug is covered under a plan, the plan may have co-pay requirements. (For example, the plan may pay for 80% of the cost of the drug, and you are responsible for paying 20% of the cost.) However, some plans will not cover fertility drugs, even though they are used on an outpatient basis.

If you are not sure if a medication is covered by your private insurance plan, call your insurance carrier before you go to the pharmacy to determine the extent of your coverage. You will need to supply the insurance company with your policy number or group health benefits number (if you do not know this number, the Human Resources manager at your employer will have it). You will also need to know the drug information number (DIN) of the particular medication you are prescribed. Fertility clinics may aid you with a pre-authorization (or predetermination letter) that can be sent to your insurance carrier prior to starting any treatment.

Rejected Claims

Is your plan not covering a drug you have been prescribed?

If your plan will not pay for a medication or if the insurance company refused a special authorization claim for a drug, here are some suggestions that may help you get the medication paid for.

  1. Call the Benefits department of the insurance company (have your benefits policy number, employer's name and the drug identification number [DIN] of the medicine you have been prescribed with you) to make sure that they are not covering the medication. Ask why they won't cover it.
  2. Let the Human Resources manager at your employer know what the insurance company told you and let her/him know your physician wants you to receive this medication and has prescribed it for you. Have her/him contact the insurance company.
  3. Determine if it is the decision of the insurance company not to cover the drug or if it is specifically excluded by the plan your employer has purchased.
  4. If your employer has purchased a drug plan for employees that doesn't cover your prescribed medication, they have the option of making an exception for this medication in this instance. Ask your employer to have the drug covered.
  5. If you are part of a patient support group ask if others have had a similar experience to yours.

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