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Drug Coverage Via Health Insurance Plans

Drug Coverage via Health Plans

Last updated: April, 2018



This in-depth article examines prescription drug coverage from a Canadian health insurance perspective. Drugs that are (and aren't) covered are listed and we also discuss other aspects of coverage such as senior's considerations and generic substitution.

Types of Health Insurance

There are two main types of Canadian health insurance: employee benefits (i.e. "group insurance") and individual health insurance (i.e. "personal" health insurance). Prescription drug coverage differs slightly depending on the type of health insurance you have.

Generally speaking, drug coverage from employee benefits does not usually have maximums, while drug coverage with personal health insurance plans does tend to have maximums (usually for the calendar year and lifetime).

NOTE: there are some personal health insurance plans such as Flexcare from Manulife Financial that let you add a Catastrophic rider (option) that allows for unlimited prescription drugs.

Prescription Drugs Always Covered

To be eligible for coverage a prescription drug must:

  1. Be prescribed by a physician, dentist or psychiatrist.
  2. Be medically necessary.
  3. Have an associated DIN (Drug Identification Number). See below for more. Note: the exception to this rule may be medical marijuana (Sun Life announced in February, 2018, that it will be adding medical marijuana to its group benefits plans).

Note that not all drugs that meet these requirements are covered. The exclusions tend to be what are called "lifestyle" drugs such as smoking cessation aids, fertility, weight loss and contraceptive drugs.

Examples of common prescription drugs that are always covered by health insurance plans are:

Prescription Drugs That May Be Covered

The following may be covered by health insurance (depends on the plan):

Important: if you want a specific prescription drug covered and are considering a health insurance plan then please contact the insurance company (or better yet an experienced, licensed broker such as ourselves) to make sure that drug will be covered by the plan you are considering!

Prescription Drugs That Are Never Covered

The following drugs are never covered by private health insurance:

DIN Numbers


A Drug Identification Number (e.g. DIN) is an eight-digit identification number assigned by Health Canada to all drugs sold in Canada, including prescription drugs.

A DIN provides information such as the drug manufacturer, the name of the drug, active ingredients, etc.

The DIN is always displayed somewhere within the drug container's label. In addition, it should be listed on the receipt from the pharmacist (see image).

To find a prescription drug's DIN number or vice versa please go the Canadian government's Drug Product Database Online Query web page.

Contraceptive Drugs

A typical employee benefits plan usually covers oral contraceptive drugs.

Individual health insurance plans, however, vary when it comes to contraceptive drugs. Generally speaking, the cheaper, "bottom end" plans do not cover contraceptive drugs while the "deluxe" or "enhanced" plans do provide coverage for oral contraceptive drugs.

Currently no health insurance plans cover what are called "birth control patch" drugs.

A flexible, affordable individual health and dental plan that offers coverage for oral contraceptive drugs is the Flexcare ConmboPlus Enhanced plan from Manulife Financial. Click here for further detials.

Fertility Drugs

Fertility drug coverage is difficult to obtain, and the type of health insurance you have (group versus individual) makes no difference.

This includes guaranteed issue health insurance plans which do not cover fertility drugs at all.

The key here is that insurance companies regard infertility as a "pre-existing condition". So, if you have discussed any infertility issues with your physician in the past then that is part of your medical history, which the insurance company has access to during the underwriting process.

Simply put, you can only get coverage for fertility drugs if you have never discussed infertility with your doctor!

Note: sometimes fertility treatments can be more expensive than the fertility drugs. Only fertility drugs are covered by health insurance, never the treatments.

Smoking Cessation Drugs

Smoking Cessation Aids

Smoking cessation drugs are considered one of the "life style" drugs, and may be covered by an employee benefits plan.

If you have group insurance please contact your advisor at the insurance company to find out if smoking cessation aids are covered by your health plan.

Very few personal health insurance plans offer coverage for smoking cessation aids.

Other Lifestyle Drugs

There are other life style drugs (besides those already mentioned above) that are covered by neither provincial healthcare plans nor by private health insurance plans. Examples are erectile dysfunction drugs such as Viagra and Cialis, and weight loss drugs.

About Generic Substitution

Many health insurance plans will not cover the costs of a proprietary, brand-name prescription drug if there is a generic, equivalent drug available. (Note that generic drugs are substantially cheaper compared to equivalent brand name prescription drugs.)

In fact, some health insurance plans go by the principle of "best cost equivalency". With "best cost equivalency" the insurance company does not cover the brand name drug cost even if there is no generic equivalent drug available. The carrier decides what the generic drug might cost if it existed, and that is the drug cost that they cover.

Generic substitution is a common practice with personal health insurance plans, and is also becoming more common with employee benefits coverage as well.

It is interesting to note that there are two personal health insurance plans that offer coverage for brand name drugs and do not use "best cost equivalency" or "generic substitution":

  1. todo tweak bookmark Flexcare ComboPlus Enhanced plan (medically underwritten plan).
  2. FollowMe Premiere plan (guaranteed issue health plan).

Drug Coverage, Seniors and Provincial Health Plans

Provincial healthcare plans in Canada cover most prescription drug costs once a person becomes 65 years old (i.e. becomes a "senior"). As a result, senior citizens get most of their drug coverage from their provincial healthcare as opposed to their private health insurance plan. For example, in Ontario seniors are covered by the "Ontario Drug Benefit Program". In Saskatchewan seniors are covered by the "Seniors' Drug Plan".

Note that dispensing fees and deductibles may not be covered by the senior's provincial healthcare plan (depending on the province of residence). In these cases, a private health insurance plan should cover those additional costs.

For province-specific senior's information please go the province's web site. You can also use the Provincial Plans links at the bottom of this web page (each provincial summary has a link at the bottom to that province's provincial healthcare web site).

Specialty Drug Coverage Programs

Each province in Canada has its own specialty prescription drug programs which tend to be for either senior citizens or low-income families.

Refer to the following for specialty provincial drug programs. Note that this is not a complete listing and is subject to change.


British Columbia:



New Brunswick:

Nova Scotia:

Northwest Territories:



Prince Edward Island:




We hope you have found this article helpful regarding prescription drug coverage, private health insurance and provincial healthcare plans. If you have anything you would like to add feel free to contact us and let us know!

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