drug coverage & access

There are basically four ways of paying for cancer drugs:

• The drug is on the list of approved medications of the government health insurance drug plan of which you are a member (either as a general benefit or through a special authorization process).
• You have a private drug plan which will pay for the drug in question (many private plans also have formularies or lists of drugs they will cover).
• You pay for the drug yourself.
• If you meet certain financial eligibility criteria, assistance may be provided by the drug manufacturer.

It may take some research to ensure you have optimal access to new prescription medications - and to minimize your own out-of-pocket costs. Here are some tips to help you.

• Know your health insurance coverage. Some provinces only provide drug coverage for people who are 65 and older or on social assistance. But others may have a variety of plans, such as special coverage for those facing substantive prescription drug costs. Drugs provided through cancer care centres can also vary from province to province. Talk with your cancer team social worker or pharmacist or call your provincial Ministry of Health to learn about all your options.
• If you have private health insurance or a drug plan at work, sit down and carefully review your benefits. If you are employed, meet with your Human Resources department or union representative to help you better understand your benefits. Ask your doctor what drugs you may need in the future, and check to see if your plan covers them. Try to coordinate the benefits so any portion of a drug cost that is not paid for by one plan is applied to the next.
• Some private insurance plans require that you pay up-front and then apply for reimbursement. If this is a problem for you (e.g. you need a very expensive drug), ask your insurance company to allow your pharmacy to send the bill directly to them.
• Don’t be afraid to advocate for yourself. For instance, if your employee health plan does not cover a certain drug, ask your employer or human resources manager if the company can make an exception in your case. Or ask your employer if they would waive the cap on your drug coverage.
• Find someone to work with you to advocate for the drug coverage you need. This someone can be a family member, for instance, or a friend. This person can help continue to advocate for you even when you cannot.
• If you are refused coverage of a medication you need, appeal. Sometimes the refusal may be the result of nothing more than faulty paperwork. And sometimes insurance companies will change their mind if you appeal.
• Some pharmaceutical companies have free services that will help you search for coverage of specific drugs or even supply you with the drug you require. Talk with your cancer care team or search online to see if you may be eligible for such a program.

For more information, check out www.DrugCoverage.ca, a free resource providing information about prescription drug reimbursement in Canada.

You may also want to regularly visit the Cancer Advocacy Coalition of Canada (www.canceradvocacy.ca) website as they provide updates on multiple myeloma treatments, drug approvals, etc.  The CACC is Canada’s only full-time, registered, non-profit cancer group dedicated exclusively to advocacy. The CACC is not a charity and operates on unrestricted grants from sponsors based on guidelines that ensure the organization’s autonomy. The CACC publishes Canada’s only independent evaluation of cancer system performance, the annual Report Card on Cancer in Canada. The Board of Directors is comprised of unpaid volunteer oncologists, health sector executives and patient advocates from across the country.