Information on private plans
Private prescription drug insurance plans are group insurance plans or employee benefit plans that cover the cost of medications. They are managed by private companies, unlike the Public Prescription Drug Insurance Plan, which is administered by RAMQ. Anyone who has taken up residence permanently in Québec must have prescription drug insurance coverage, as required under the Health Insurance Act.
Access to a private plan and obligations
You must join a private plan, at least for the prescription drug insurance portion, if you have access to one and are under age 65. In addition, you have to provide coverage under this plan for your children and spouse, if they are not already covered by another private plan. You must do the same for a person with a functional impairment who is living with you. You can access a private plan in the following ways:
- Through your employment or profession (via your employer or professional organization: union, association or order)
- Through your spouse
- Through your parents
If you do not have access to a private plan, you must register with the Public Prescription Drug Insurance Plan.
Minimal conditions of coverage
All private insurance plans must offer basic medication insurance coverage. This means that the private insurance must, at the very minimum, include the medications covered by the public plan, i.e. those appearing on the List of medications. The covered medications include exceptional medications and the medications covered under the exception program for patients with a serious medical condition.
Certain private plans cover medications only. Others cover supplemental services, such as consultations with health professionals (e.g. physiotherapists and chiropractors), eye care and/or dental care. As you can see, apart from basic medication coverage, the coverage afforded by various private plans may differ.
Private plan costs
As a rule, you pay a premium for coverage under a private plan. In addition, you contribute toward the cost of your covered medications until you reach a maximum amount. Your insurer also pays its part of the cost of the medications. It may reimburse you in various ways.
Persons covered by a private plan must usually pay a premium, whether or not they purchase medications. The amount of the premium is negotiated between the insurer and the employer (or professional group). The Act respecting prescription drug insurance requires that employers deduct the premium from the remuneration of each insured person and pay it to the insurer.
Payment of covered medications purchased at the pharmacy generally includes, as does the public plan, a contribution on your part. This contribution often comprises the following:
- Deductible: Set amount paid when making your first purchases. In the case of private plans, the deductible is usually paid annually. Some private plans have no deductible.
- Co-insurance: Percentage of the price of a medication that you have to pay. It applies once you have paid the deductible.
The Act respecting prescription drug insurance sets out an annual maximum contribution, or ceiling. The maximum set by a private plan must be equal to or less than the amount stipulated in the Act. Once the maximum has been reached, the insurer pays all medication costs for the remainder of the year. When you purchase medications at a pharmacy, you continue paying for non-covered medications only and, according to your insurance contract, any excess amount.
You must check with your insurer to find out how it reimburses you its portion of the cost of your medications. You may be reimbursed at the time of purchase or afterwards. You may or may not have to submit a claim.
At the time of purchase
You only pay your contribution toward the cost of the medication when you purchase it at a pharmacy. Your insurer then pays its portion to the pharmacist.
After your purchase, no claim necessary
You pay the pharmacy the full cost of the medication. Next, the pharmacist submits a claim to your insurer on your behalf. You then receive the reimbursement, for example, by cheque or direct deposit.
After your purchase, claim necessary
You pay the pharmacy the full cost of the medication. Next, you submit a claim to your insurer, attaching the invoice or receipt for the medications purchased. You then receive the reimbursement, for example, by cheque or direct deposit.
Employer’s choice as to whether or not to offer group insurance
The employer can choose whether or not to offer group insurance to its employees. The same is true for a professional order or association toward its members. The employer or professional order or association comes to an agreement with its insurer on the conditions of the plan, such as the percentage of coverage and the eligibility criteria.
Are you an employer or insurer and wish to find out more about your responsibilities? The responsibilities of employers and insurers (French only)
Private plan eligibility criteria
Your employer or professional association or order may have eligibility criteria. For instance:
- Participation in the plan after a waiting period of 3 months for a new employee or new member
- Restricted access depending on a minimum number of hours worked per week or a minimum income threshold
- Exclusions applying to part-time, casual, contract, laid-off or retired employees
You must register with another plan if you do not qualify for the plan offered by your employer or professional association or order.
Criteria that may not be used to deny coverage
No insurer may deny you coverage for risks related to age, sex or health condition. Furthermore, the insurance must be maintained during certain temporary absences, such as sick leave or maternity leave. For your part, you must remain insured and pay your insurance during the absence.
If you have access to several private plans
If you have several private plans to choose from, you can choose the one that is most advantageous. This may happen, for instance, if you can both access your spouse’s private plan and the one offered by your employer.
If you do not join your employer’s plan, you must provide it with proof that you are covered by another private plan. Otherwise, your employer will have to deduct a premium from your salary. Certain employers require that their employees join their private plan as a condition of employment. In such case, you have to pay the premium.
Proof that you are covered
- An official letter from the other employer or professional order or association
- An official letter from the other private insurer
When you turn 65, you will be automatically registered with the Public Prescription Drug Insurance Plan. However, if you qualify for a private plan, you will have to make a choice.
To find out more, go to the webpage Turning 65.