Introduction to MS medication reimbursement

What is medication reimbursement?

Medication reimbursement is the process of having some or all of your medication costs paid for by an outside source, such as an insurance company, government, or other program. Getting reimbursement for your MS medications can help reduce your expenses and make it easier to get access to the treatments you need.

How are MS medications reimbursed in Canada?

There are three main ways that you can get reimbursement for your MS medication.

Government coverage: Drug coverage is usually handled by the provincial government, although there are federal government drug programs that cover some people, including certain government employees, members of the Canadian Forces, refugees, and inmates in federal prisons.

Most provincial drug plans cover the majority of MS disease-modifying medications for people who are eligible for these plans. The exact coverage, what you need to qualify, and how much you will need to pay out of your own pocket differs by province, and it often depends on your family's income. Some provinces also offer special coverage for people facing high medication costs not covered by private plans. For more information, contact the MS Society of Canada, which can direct you to the appropriate information source for your province.

Private insurance: Most Canadians have some form of private insurance, either through their employer or through drug insurance plans that they have purchased themselves. Private drug insurance is offered by a variety of insurance companies in Canada, and many different plans are available.

Some plans pay all of the cost of the medication, but many plans require the person to pay some of the costs themselves, either as a small percentage of the total costs (co-payments, or simply co-pays), as a fee with each prescription (co-pays), or up to a fixed maximum amount each year (deductibles). The exact details depend on the plan.

Although many private plans cover MS medications, most plans also limit the total amount that they will pay for medications in a given year (caps), and this amount is often less that the total yearly cost of disease-modifying medications for MS. If this is the case, you may need to apply for additional drug coverage through a government plan or pay for the costs out of your own pocket. Many provinces have plans that help pay for costs not covered by private plans.

Some private plans provide you with a drug card that allows your pharmacy to bill your insurance company directly for the cost of the medication. Other plans require you to pay for the medication up front, and then submit a claim form to have the costs reimbursed later.

Out-of-pocket: You can pay the costs yourself out of your own pocket. However, given the fact that other insurance options are available, it's a good idea to see whether you may be eligible for private or government insurance coverage before paying all of the costs yourself. For more information, speak to your doctor, call your local MS society, or contact the manufacturer of your MS medication.

Other sources of medication reimbursement: If you are in the hospital, the costs of any medications you may need during your hospital stay will be covered by the hospital's budget. However, this only lasts until you leave the hospital.

In some cases, you may be eligible for a compassionate program from the pharmaceutical company that makes your MS medication. These programs may cover the cost of your MS medication while you are waiting for your private or government coverage to come through.

For more information on MS medication reimbursement, see "Finding the reimbursement you need."

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