Amount to pay for prescription drugs
Insured persons must inform the pharmacist that they are registered for the public plan and present their valid Health Insurance Card, along with their 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) if applicable.
When insured persons purchase covered drugs, they pay only a portion of their cost. This is called their contribution, i.e. the deductible Deductible
The deductible is a fixed amount that constitutes the first portion of the costs that insured persons must pay when obtaining insured drugs. plus the co-insurance Co-insurance
The co-insurance is the percentage (or portion) of the drug costs that insured persons must pay once they have paid the deductible. In other words, when a person's drug costs exceed the deductible, the person pays only a portion of the remainder. This
portion is what is referred to as the co-insurance.. The other portion is paid by the Régie de l'assurance maladie du Québec.
For persons covered by the public 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., the deductible is a monthly amount that they generally pay in full when making their first drug purchase during the month. The amount of the deductible is adjusted on July 1 of each year.
For persons covered by 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., the deductible is generally a yearly amount. Certain private plans do not require members to pay a deductible.
EXAMPLE
A $60 prescription presented at the pharmacy on July 1, 2012
Monthly deductible Deductible
The deductible is a fixed amount that constitutes the first portion of the costs that insured persons must pay when obtaining insured drugs. |
Co-insurance Co-insurance
The co-insurance is the percentage (or portion) of the drug costs that insured persons must pay once they have paid the deductible. In other words, when a person's drug costs exceed the deductible, the person pays only a portion of the remainder. This
portion is what is referred to as the co-insurance. |
Contribution paid by the insured person Contribution paid by the insured person at the pharmacy
Total of the deductible plus the co-insurance. The insured person pays that amount at the pharmacy. |
Amount paid by the Régie |
|
| Fixed amount paid when making the first drug purchase during the month. |
32% of the cost of the prescription minus the deductible |
Total of the deductible plus the co-insurance |
Cost of the prescription minus the contribution by the insured person |
|
$60 - $16.25
=
$43.75 x 32%
= |
$16.25
+
$14
= |
$60
-
$30.25
= |
| $16.25 |
$14 |
$30.25 |
$29.75 |
Rates in effect for adults age 18 to 64 and for persons age 65 or over who are no longer receiving any Guaranteed Income Supplement GIS (Guaranteed Income Supplement)
The Guaranteed Income Supplement (GIS) is an amount added to the Old Age Security Pension (OASP) and is paid at the same time as that pension to certain persons age 65 or over. A person may receive the maximum GIS (100%), a partial GIS or no GIS (0%), depending on the family income. In each case, the contribution to the public plan differs. (GIS) or receiving 1% to 93% Rate
Rate calculated according to the Act respecting prescription drug insurance. of the GIS. |
When you have a prescription refilled early, you pay for your drugs as though you were purchasing them on the refill date. For example, if the refill date for your prescription occurs during the following month, you pay the deductible Deductible
The deductible is a fixed amount that constitutes the first portion of the costs that insured persons must pay when obtaining insured drugs. and the co-insurance Co-insurance
The co-insurance is the percentage (or portion) of the drug costs that insured persons must pay once they have paid the deductible. In other words, when a person's drug costs exceed the deductible, the person pays only a portion of the remainder. This
portion is what is referred to as the co-insurance. for the following month, just as if you were making your purchase during that month.
Maximum annual contribution
There is a maximum annual amount that insured persons may be required to pay per month and per year to obtain drugs covered by the the public plan. This maximum amount includes the deductible Deductible
The deductible is a fixed amount that constitutes the first portion of the costs that insured persons must pay when obtaining insured drugs. and the co-insurance Co-insurance
The co-insurance is the percentage (or portion) of the drug costs that insured persons must pay once they have paid the deductible. In other words, when a person's drug costs exceed the deductible, the person pays only a portion of the remainder. This
portion is what is referred to as the co-insurance..
Thus, persons who reach their maximum monthly contribution can generally obtain their insured drugs free of charge until the end of the month.
Here is how your contribution is calculated.
Amounts in effect from July 1, 2012 to June 30, 2013
|
Maximum MONTHLY contribution |
Maximum ANNUAL contribution |
|
| Persons age 18 to 64 not eligible for a private plan |
$82.66 |
$992 |
| Holders of a claim slip (issued by the Ministère de l'Emploi et de la Solidarité sociale) |
$0 |
$0 |
| Persons age 65 or over: |
| No Guaranteed Income Supplement (GIS) |
$82.66 |
$992 |
1% to 93% Rate
Rate calculated according to the Act respecting prescription drug insurance. of GIS |
$50.97 |
$612 |
94% to 100% Rate
Rate calculated according to the Act respecting prescription drug insurance. of GIS |
$0 |
$0 |
| The Régie sends this GIS information to the pharmacist, so that the persons will pay the proper amount when purchasing prescription drugs. |
| Free of charge for children insured under the public plan: |
| If they are under age 18 |
$0 |
$0 |
| If they are age 18 to 25, are full-time students in 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. |
$0 |
$0 |
For certain covered drugs, insured persons may have to pay an excess amount Excess amount
In the case of certain covered prescription drugs, a maximum payable price (MPP) has been set. When they purchase these drugs, persons insured under the public plan may have to pay an additional amount. This excess amount corresponds to the difference between the price requested by the drug manufacturer and the maximum price reimbursed by the Régie. It is not taken into account when calculating the insured person's maximum monthly contribution.Persons insured under the public plan may also be required to pay an excess amount if they choose to purchase a costlier drug than the equivalent payable by the Régie., which is not taken into account when calculating the monthly contribution. This excess amount corresponds to the difference between the price requested by the drug manufacturer and the maximum price paid by the Régie.
There is a maximum amount (ceiling) that insured persons may generally pay per 12 month period to obtain covered drugs. Once the ceiling is reached, the private plan meets all the costs of covered drugs until the end of the period.
Contact your insurer Insurer (of persons)
A legal person that holds a permit issued by the Autorité des marchés financiers authorizing it to transact personal insurance in Québec and that assumes, in return for a premium paid, the financial consequences resulting from one or more risks specified in the contract signed by the parties. to find out the amount of the maximum annual contribution provided for in your contract and to find out when your 12-month period begins.
Remember that the amount of the maximum annual contribution must not exceed the amount provided under the Public Prescription Drug Insurance Plan, which is set each year on July 1.
Public plan rates
In actual fact, persons who reach their maximum annual contribution may still have to continue paying for the insured drugs they purchase.
However, in such cases, their insurer reimburses them for 100% of the amounts they pay during the rest of the year, instead of only for a portion (e.g. 80%) of those amounts.
Drugs free of charge for certain persons registered for the public plan
Persons age 65 or over who are receiving 94% to 100% Rate
Rate calculated according to the Act respecting prescription drug insurance. of the Guaranteed Income Supplement (GIS) GIS (Guaranteed Income Supplement)
The Guaranteed Income Supplement (GIS) is an amount added to the Old Age Security Pension (OASP) and is paid at the same time as that pension to certain persons age 65 or over. A person may receive the maximum GIS (100%), a partial GIS or no GIS (0%), depending on the family income. In each case, the contribution to the public plan differs. are entitled to prescription drugs free of charge. Generally, they have nothing to pay at the pharmacy.
This is also the case for the 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 insured under the public plan if they are under age 18 or if they meet the following 4 conditions: they are 18 to 25, full-time students in an educational institution recognized by the Ministère de l'Éducation, du Loisir et du Sport, without a 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 live with their parents.
Obtaining a reimbursement from a private insurer
The method of calculating the contribution and the procedure for obtaining a reimbursement vary from one private plan to another. Since each insurance company determines its own procedure, it is necessary to check with the insurance company to find out what that procedure is.
There are basically 3 ways to be reimbursed by an insurer.
1. Payment of the contribution at the time of purchase
Some insurance companies have concluded agreements with pharmacies whereby insured persons pay only the amount of their contribution when purchasing drugs. The insurer pays the pharmacy the difference, which saves them from having to file for a reimbursement.
2. Reimbursement after purchase (no steps need be taken)
Insured persons pay for their drugs in full at the time of purchase. The pharmacist then submits a claim to their insurer, which issues them a reimbursement. Insured persons therefore have no steps to take.
3. Reimbursement after purchase (steps must be taken)
Insured persons pay for their drugs in full at the time of purchase. Thereafter, they must themselves submit a claim to the insurer, along with the receipt or invoice for the drugs purchased. The insurer then sends them a reimbursement.
Changing plans
Persons who change insurance plans (from a private plan to the public plan or vice versa, or from one private plan to another) must themselves take certain steps to make sure they don't exceed their maximum annual contribution.
They must, within 6 months of the transfer, ask their original insurer to provide them with a statement of their contributions for the current year. Some insurers, including the Régie de l'assurance maladie du Québec, issue the statement automatically, while others issue it only on request. Here is a model statement, intended for persons transferring from a private plan to the public plan.
They must send their statement of contributions to their new insurer, which will be able to take it into account in making sure their maximum contribution is not exceeded.