Private Drug Coverage

If you are paying for any of your medications through private insurance, here is a helpful guide to ensure a smooth process.
Print and use this form while referring to the following guide:
PRIVATE PLAN INFO

Before you contact your insurance company, gather information about the drug(s) you need to ask about. For this example, let’s use the drug “Neulasta”. To begin, let’s find the Drug Identification Number (DIN). You can find any Health Canada approved drug number here or you can refer to our own list of Cancer Drugs & DINs. The DIN for Neulasta is: 02249790.

The next step will be to contact your insurance provider to inquire into your coverage. You may have a drug card from your insurer with a policy number, certificate number or group number. Ensure you have these ready when you call.

Important Questions

IS THE MEDICATION COVERED BY MY PLAN?

Coverage will depend on your plan and the formulary of drugs they have decided to fund.

WHAT PERCENTAGE WILL MY PLAN COVER?

A typical amount covered is 80%. However, your coverage could be higher or lower depending on your plan. If you have less than 100% coverage and are in need of a very expensive drug, ask your cancer clinic pharmacy if there are any programs available to help pay the cost difference.

IS THERE AN ANNUAL FINANCIAL LIMIT OR CAP ON MY PLAN?

For expensive drugs, a limit can be reached quickly. It is important to know how long you will be on the drug to determine the overall cost.

IS THERE ANY "PRIOR AUTHORIZATION" NEEDED FOR THIS MEDICATION TO BE COVERED?

If you require prior or special authorization for your drug, a form can be printed from online and provided to your physician to complete. Ensure that you also sign it and include your personal information.

When speaking with your insurance provider over the phone, keep the name agent who speaks with you for your records, as well as the time and date of the call. Calls are usually recorded and you will be able to refer back to a previous call if there are any issues later on.

How to check your private insurance plan

You can contact your local oncology Drug Access Navigator here

Dealing With a Denial From Your Insurer

  • When speaking with your insurance provider over the phone, keep the name agent who speaks with you for your records, as well as the time and date of the call. Calls are usually recorded and you will be able to refer back to a previous call if there are any issues later on.
  • You may also let your Human Resources department know that you have been given a denial from the insurer. It may be possible to have an exception granted for your medication depending on the reason for the denial and the plan your employer purchased.
    Examples:
    – Denied due to lack of medical evidence.
    – Denied due to drug not being in the insurer formulary (list of covered drugs)
    – Denied due to the cost of the drug
  • Keep notes, including names of individuals spoken to, or any phone/email conversations. This will allow you to follow-up better with anything the insurer agents tell you.
  • Keep copies of all appeals and supporting information provided to the insurer.
  • If you are part of a patient support group, ask if others have had a similar experience to yours.
  • If you have a low financial maximum on your plan, you can also appeal this to your employer. It may be possible to have the limit increased just for the drug you need. If it is only needed for a particular amount of it, you should inquire with your employer to see if an exception can be granted.