The Costs – At the Pharmacy

Insured persons pay only a portion of the cost of the drugs they purchase. This portion is called their contribution. The other portion is paid by their insurer.

Certain private plans allow the persons they insure to pay the pharmacy only the amount of their contribution, while other plans require them to pay the pharmacy in full at the time of purchase and reimburse them afterwards for the difference.

The method of calculating the contribution and the procedure for obtaining a reimbursement vary from one private plan to another. Here are a few general explanations.

How is the contribution calculated?

The amount payable usually consists of a deductible and a co-insurance amount.

• The deductible is the first portion of a person's drug costs and is usually applicable to a one-year period. For example, a plan may require insured persons to pay the first $50 of their drug costs for the year, and only the co-insurance thereafter.
• The co-insurance is a percentage of the person's drug costs that exceed the deductible.

How is a reimbursement obtained from an insurer?

There are basically three ways to be reimbursed by an insurer. Since each insurance company determines its own procedure, it is necessary to check with the insurance company to find out what that procedure is.

• 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.
• 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.
• 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.