Eligibility
The Public Prescription Drug Insurance Plan Public plan
The Public Prescription Drug Insurance Plan is administered by the Régie de l'assurance maladie du Québec and is intended for persons who are not eligible for a private group insurance plan covering prescription drugs, for persons age 65 or over, and for recipients of last-resort financial assistance and other holders of a claim slip (carnet de réclamation). Children of persons registered for the public plan are also covered by that plan. is intended for:
- persons who are not eligible for a private plan Private plan
Private plans are usually available in the form of group insurance or employee benefit plans. Persons may be eligible for a private plan through employment, through membership in a professional order or association, or through their spouse or parents. Persons who are eligible for a private plan are required to join that plan.;
- persons age 65 or over;
- recipients of last-resort financial assistance Last-resort financial assistance
A program administered by the Québec government, providing financial support to persons with limited resources. A person receiving last-resort financial assistance benefits is automatically registered for the Public Prescription Drug Insurance Plan when his or her file is created. and other holders of a claim slip Claim slip (carnet de réclamation)
The Ministère de l'Emploi et de la Solidarité sociale issues claim slips to recipients of last-resort financial assistance and, in certain conditions, to adults or families not receiving last-resort financial assistance benefits. Holders of claim slips can obtain certain drugs prescribed by a doctor and certain services, such as eye examinations and dental care.(carnet de réclamation) ;
- children Children
Children are persons who are under age 18 or persons age 18 to 25 inclusive, are full-time students at an educational institution recognized by the Ministère de l'Éducation, du Loisir et du Sport, do not have a spouse and live with their parents. Persons age 18 or over are considered children if they are spouseless, have a functional impairment that began before age 18, are not receiving last-resort financial assistance benefits, and are domiciled with someone who would exercise parental authority over them if they were a minor. of persons covered by the public plan.
Persons who have only the supplemental coverage Supplemental coverage
Supplemental coverage is offered by certain private plans to persons age 65 or over. This coverage does not replace the basic coverage, but may add to such coverage, for example, by paying for uninsured drugs or by paying a portion of costs not
reimbursed to persons who have only the basic coverage. A private insurer offering supplemental coverage acts as the second payer for prescription drugs. offered by a private plan must also have the basic coverage provided by the public plan and must therefore pay the public plan premium.
Everyone under age 65 who is eligible for a private plan is required to obtain at least the prescription drug coverage provided by that plan. Most private plans (often called health insurance plans) offer prescription drug coverage along with other healthcare coverage, but some offer prescription drug coverage only.
Persons who turn 65 and who are eligible for a private plan that offers basic prescription drug coverage Basic coverage
Basic coverage is the minimum prescription drug insurance coverage that all Quebecers must have and includes all drugs listed on the List of Medications, published by the Régie de l'assurance maladie du Québec and listing over 5 000 drugs available on prescription. For the cost of these drugs to be reimbursed, they must be dispensed by a pharmacist. may either retain their private plan coverage or join the public plan, administered by the Régie de l'assurance maladie du Québec. For information about the various options available, consult the page entitled Turning 65.
Private plans are available either through employment, through membership in a professional order or association, or through a person's spouse or parents. Those who are covered by a private plan are required to obtain coverage under it for their spouse and children, unless their spouse Spouse
Two persons (of the opposite sex or the same sex) are considered spouses if they are married and have entered into a civil union, or have been living together for 12 months (separations of less than 90 days do not interrupt the 12-month period), or are living together (regardless of for how long) and together have had or have adopted a child. and children Children
Children are persons who are under age 18 or persons age 18 to 25 inclusive, are full-time students at an educational institution recognized by the Ministère de l'Éducation, du Loisir et du Sport, do not have a spouse and live with their parents. Persons age 18 or over are considered children if they are spouseless, have a functional impairment that began before age 18, are not receiving last-resort financial assistance benefits, and are domiciled with someone who would exercise parental authority over them if they were a minor. are already covered by another private plan. Furthermore, whomever is eligible for more than one private plan may choose the plan they consider the most advantageous.
Persons who are eligible for a private plan cannot be covered by the public plan.
Check your situation to avoid unpleasant surprises
If you are registered for the public plan while being eligible for a private plan, you will have to repay the Régie the amount it paid for any prescription drugs obtained during your period of non-eligibility for the public plan.
Moreover, if you are not covered by prescription drug insurance, which is compulsory, you will have to pay Revenu Québec an amount equivalent to the public plan premium for every full month during which you had no coverage at all. The Régie, together with Revenu Québec, checks compliance on a regular basis. Therefore, to avoid unpleasant surprises, check your situation by completing a short questionnaire.
Do you need to register for or deregister from the Public Prescription Drug Insurance Plan? We invite you to do so online
(if your family situation and age allow you to use this service).
Application for review
If you disagree with a decision of the Régie, you can apply for an administrative review. You have 6 months, from the date the letter of decision is deposited in your mailbox or handed to you in person, to contest the decision.
Form to fill out
First, you must fill out an Application for review.
To appeal a decision regarding healthcare received outside Québec, a technical aids program or a financial assistance program, you must use the form also.
It is important that you enclose the relevant original documents (bills, proof of payment, medical documents, etc.) and you specify the matter being contested, and any facts and dates to be corrected. If you need more space than that provided on the form, attach a separate, signed sheet.
Send your application for review to the following address:
Direction de la révision
Régie de l'assurance maladie du Québec
Case postale 6600
Québec (Québec)
G1K 7T3
We recommend that you keep copies of the documents provided.
Analysis of your application for review
The agent of the Régie who analyzes your application for review will contact you, if required, to clarify your expectations. If necessary, the agent will assist you in the process of gathering relevant information to complete the file.
The review of your application is based on the new information provided by you and the documents already on file. Those documents must cover the entire period at issue. Missing information may delay the processing of your file.
After the agent has reviewed your file, he/she will notify you in writing of the Régie's new decision.
The Régie's commitment
We will process your application in keeping with our values: respect, responsibility, fairness and attentiveness.
We also undertake to follow up on your application for review within 40 days of receiving it, if your file is complete.
The Régie's decision
Under the Health Insurance Act, the Régie has 90 days to render its decision following an application for review.
If, after you've filed your application, you wish to provide supporting documents or comments, the 90-day time limit will run from the date the Régie receives the documents.
Moreover, if the Régie deems that it needs additional documents or information, it may extend the time limit by another 90 days.
Finally, if the Régie does not meet the deadlines, you may wait for its new decision, or contest the previous decision before the Tribunal administratif du Québec (TAQ).
Do you disagree with the Régie's new decision?
If you believe that the decision rendered in follow-up to your application for review does not respect your rights, you have 60 days (from the date the decision is delivered to your address) to contest it before the TAQ.