Know the conditions for coverage
The Public Prescription Drug Insurance Plan covers over 8,000 prescription drugs. The drugs and the conditions of coverage are set out in the List of Medications, which is updated on a regular basis. Exceptionally, a drug may be covered even if it not included on the list.
Conditions for the coverage of prescription drugs
Generally, the public plan covers the prescription drugs:
- Specified on the List of Medications
- Prescribed by health professionals
- Purchased in Québec from a pharmacist
- Sold at the lowest price (coverage of the less expensive generic versions instead of the brand name drugs, for example)
When you purchase prescription drugs that are covered under the public plan, you usually pay a portion of their cost: the contribution. To find out more, refer to the webpage Amount to pay for prescription drugs.
Which drugs are covered
The Minister of Health selects which drugs are covered following consultations with the Institut national d’excellence en santé et en services sociaux (INESSS). The Minister also decides on the replacements for covered drugs that are out of stock. To find out more, refer to the page Drug Products Undergoing Evaluation and Evaluated on the website of INESSS.
Coverage of generic drugs
The public plan covers generics rather than their brand name version if the former is less costly. Please note that you will have to pay the difference between the price of a brand name drug and an equivalent generic if you purchase the brand name drug. Certain exceptions apply.
Difference between a brand name drug and equivalent generic version
Brand name drugs are products that have been patented by pharmaceutical companies. Generics are copies, which cost less; they contain the same medicinal ingredients and are approved by Health Canada according to the same quality standards.
Brand name drugs with the mention “Ne pas substituer” (do not replace)
The public plan will cover brand name drugs if “Ne pas substituer” (do not replace) is written on them, along with any of the following justifications:
- You suffer from a documented allergy or intolerance to a non-medicinal ingredient present in the less costly generic name drug, but absent in the brand name drug.
- The drug being prescribed is a brand name drug whose dosage form is essential to obtain the expected clinical results, and this drug is the only one appearing on the List of Medications in this form.
You don’t have to pay the difference between the price of brand name drugs and their generic copies if you obtained them at a pharmacy before June 1, 2015 with the mention “Ne pas substituer”, even without justification:
- Clozapine: ClozarilTM
- Immunosuppressors: CellceptTM, MyforticTM, ImuranTM, RapamuneTM, PrografTM and AdvagrafTM
For these drugs, you do not need to obtain a justification from your prescriber. However, make sure that your new prescriptions still bear the mention “Ne pas substituer” (after June 1, 2015).
Coverage of biosimilar drugs
Biologic drugs are drugs produced from living cells and patented by pharmaceutical companies. Biosimilars are very similar copies of biologic drugs, which cost less. When biosimilars are marketed, the brand name biologic drug to which it is compared is called the reference biologic drug. The public plan covers biosimilars specified on the List of Medications.
Exceptions
Reimbursement of a brand name biologic drug is only authorized in the following cases:
- There is no covered biosimilar version of this drug or until 6 months after the listing of such a version to the List of Medications
- A woman is pregnant (including the 12 months following delivery)
- The request for reimbursement concerns a child or for the remaining duration of their authorization, for a maximum of 12 months following the date of their 18th birthday
- In case of a therapeutic failure with at least 2 other drugs biologic drugs used to treat the same medical condition
Copay cards
Since April 15, 2021, manufacturers, wholesalers and intermediaries have been prohibited from paying pay you, even partially, for a supply or drug covered under the Public Prescription Drug Insurance Plan or a private plan. This prohibition applies to any form of financial assistance: copay cards, reductions, reimbursements, free doses, etc.
Exceptions
If you obtained this type of financial assistance before April 15, 2021 for a prescription drug, you may continue receiving it for as long as you take this drug. However, if you change drugs or brands, the exception will cease to apply.
This form of financial assistance will also be allowed:
- For a drug that is not covered by the public plan or a private insurance plan
- In the case of free doses of a drug pending the approval of a reimbursement by an insurer
- For a drug not having a covered generic version. Where such a version of a drug does appear on the List of Medications, you will have a 30 day transition period before the exception ceases to apply.
Prescription drugs covered in certain situations
The public plan may cover drugs obtained in particular situations, under certain conditions.
As a rule, the public plan does not cover prescription drugs purchased outside Québec. However, there is an exception: the plan covers prescription drugs purchased in certain pharmacies in areas bordering Québec if:
- The pharmacy has concluded an agreement with RAMQ
- No Québec pharmacy serves the public within a 32-kilometer radius of this pharmacy
The prescription drug coverage obtained during a hospitalization or an extended stay in a CHSLD differs according to the type of facility: whether it is under agreement or not.
Public CHSLD or private CHSLD under agreement (subsidized with public funds) | Public CHSLD not under agreement (not subsidized with private funds) |
|---|---|
Nothing to pay: Your prescription drugs are fully covered by hospital insurance. | Generally, you continue to pay a contribution toward the cost of your drugs. |
The public plan covers, under certain conditions, the prescription drugs indicated in the “Exceptional medications” section of the List of Medications. There are 2 types of exceptional medications:
- Coded: Your health professional writes a code on the prescription so that it will be covered. You can then obtain your prescription drug at your pharmacy without delay.
- Uncoded: Your health professional must send us an authorization request before your prescription drug can be covered. You will be able to obtain it at your pharmacy once authorization has been granted.
Authorization requests processing times
- 1 working day for a priority exceptional medication marked with a star in Appendix IV to the List of medications
- 25 working days for any other exceptional medication if the request is complete
The public plan covers certain prescription drugs, notably, those not on the List of medications, for insured persons with an exceptional need. In such case, your health professional, for instance, your physician, will send us an authorization request so that you may qualify for this program. If authorization is granted, your prescription drug will be covered and you will be able to obtain it at your pharmacy.
Authorization requests must be examined: response time may exceed 25 working days.
Certain stop-smoking products are covered by the public plan when prescribed by health professionals:
- Skin patches
- Nicotine gum and lozenges
- Stop-smoking tablets: Bupropion and varenicline
Their coverage is limited to a maximum of 12 consecutive weeks per 12-month period, starting on the purchase date. Other conditions apply:
| Skin patches, nicotine gum or lozenges | Product in tablet form |
|---|---|
|
|
Certain proton pump inhibitor (PPI) class drugs are covered by the public plan.
To qualify for a reimbursement, you must:
- be insured by the Public Prescription Drug Insurance Plan
- have a prescription for a PPI class drug
If you are 18 or older, eligible PPI class drugs are covered for a maximum of 90 days of treatment in any 365 day period.
Reimbursement conditions
- The 1st period of 90 days of treatment begins when you purchase your 1st PPI class drug.
- Under certain conditions, you may obtain extended coverage for a period of 12 to 24 months. For this to apply, your prescription must indicate the code corresponding to the health problem requiring the taking of this drug.
Drugs targeted by this measure
- ParietTM (rabéprazole) et ses génériques
- PrevacidTM (lansoprazole) et ses génériques
- Prevacid FasTabTM (lansoprazole) and its generics
- PantolocTM (pantoprazole) and its generics
- TectaTM (pantoprazole) and its generics
- LosecTM (omeprazole) and its generics
- NexiumTM (esomeprazole) and its generics
- DexilantTM (dexlansoprazole)
The reimbursable quantity of blood glucose test strips is subject to certain rules. The Public Prescription Drug Insurance Plan covers the purchase of a limited number of strips per year.
We determine the reimbursable quantity of strips based on to your health condition, according to your risk of hypoglycemia. The maximum number of strips is calculated per 365-day period as of the 1st purchase of strips. The health professional in charge of your follow up may allow you to obtain additional strips per 365-day period for specific health problems.
Reimbursable quantity of strips depending on your health condition
| Quantity | Health condition |
|---|---|
| 200 |
|
| 400 |
|
| 3,000 |
|
Exception for non-diabetic persons
The strips may also be reimbursed in the case persons who are not diabetic, but suffering from rare health problems and at risk of developing potentially severe symptomatic hypoglycemia. To find out if you are in one of these situations, consult your physician.
Application for review
You can apply for a review of a RAMQ decision. To find out more, refer to the page Request a review of a decision.