Access to Medications in Canada
Canadians may assume that we have a completely publicly funded health care system. Services deemed medically necessary by Canada’s Health Act are provided for (ie.hospital, diag-nostic and physician services). However, most Canadians must cover items such as dental, vi-sion and prescription drug costs privately. Canadians must use private insurance or pay out-of-pocket for 30 per cent of health costs, with only about 70 per cent covered by our publicly fund-ed health system.
Psoriasis and psoriatic arthritis are usually treated on an outpatient basis so patients are respon-sible for covering costs of prescribed medications. Over half of Canadians have private cover-age for prescription drugs, usually through their employers. A majority of other Canadians are covered by the government by provincial, territorial or federal drug programs. And others have no coverage at all.
It is important to have a good understanding of your health insurance coverage. Know whether you're covered through your employer, federal programs or the province you live in, or by your own private insurer. If you are not covered by health insurance this section will steer you toward government programs or other options that can help you.
A common stepped approach seen below, is typically followed for psoriasis treatments. This may reflect medical practice and is also driven by the coverage.
Common Stepped approach for Psoriasis treatments
Your doctor can help
Ask your doctor directly, "If money were no object, what would you recommend for me?" This would enable the doctor to make a recommendation based on what they think is best for you regardless of coverage status. Doctors know that some of these treatments are expensive, and may recommend a treatment that you can afford or is covered on your plan, skipping the treat-ment they really think would help.
If it has been your family physician working with you up to this point, your condition may require further expertise of a dermatologist or a rheumatologist. Ask your family physician to refer you to a specialist for an assessment. Having a specialist can, in some cases, improve your chances for coverage of newer treatments.
Once you have the prescription from your physician, you will have better access to ALL the fi-nancing options to help cover your treatment costs. Most of the pharmaceutical patient financial support services require a prescription before you can apply for financial coverage.
Types of Coverage
Some psoriasis drugs have limited access even if you have private insurance. You must first learn from your physician which medication he/she recommends, and then you need to contact your insurance company to learn if you are covered for the medication prescribed.
Virtually all plans that cover treatments have either a stepped approach or a tiered one, or in some cases both. For a stepped approach, you need to have tried, without a successful out-come, generally cheaper treatments before they will cover the one or ones on a higher step.
For tiered programs, there are tiers within a given step, based entirely on the cost of each medi-cation to the insurer. If you try and access a medication on a higher tier without having tried a lower tier one, you will likely be asked for a higher co-pay , or coverage is denied.
When consulting with your physician for treatments, be open and honest about your overall physical, mental health, and overall medical history . Your physician may discover that a treat-ment required by your drug plan may not be safe or appropriate given your past experience or other health issues you may have. In such cases, you may be able to 'skip' a step or two and move forward with the medication on a higher step. Also, in some cases for those psoriasis pa-tients with sore or inflamed joints, a prescription written by a rheumatologist may be covered when the same prescription may be denied if prescribed by a dermatologist.
Insurance companies are coming up with new ways to cut their costs which could impact your choices. To learn more about troubling issues with insurance companies' coverage of psoriasis treatments, visit our partner site (www.canadianskin.ca in the Advocacy section, then to go the Protecting Patient Choice page).
For more information on private insurance please see “Private Insurance” section
Each provincial or territorial government covers medication differently. For more information details of which medications are covered and the qualifications for public coverage please see “Public Insurance’ Section
For those without private or public drug coverage, or if access is denied, there are other avenues available. For more information on such programs see “Other Options for Access” section
CAPP Position on Access for Patients
While effective treatments are available for both psoriasis and psoriatic arthritis, many patients experience difficulties obtaining them. There are deficiencies and disparities in access to derma-tological care and treatment across the country. Please see “CAPP Position on Access” section for recommendations and foundation of the advocacy initiatives of the organization.