Canadian Drug Coverage: Understanding Canadian Drug Coverage
October 22, 2018

Understanding Canadian Insurance Coverage and the discrepancy in current data

The proportions of public and private prescription drug coverage vary substantially between provinces in Canada. Variations in prescription drug coverage in different provinces can likely be attributed to availability and cost of public prescription drug coverage plans, as well as differing provincial legislation on mandatory coverage and eligibility.

Medlior explores the proportions of Canadians with public and private prescription drug coverage, as well as the proportions who are uninsured. In addition, we provide an overview of the public prescription drug plans available in each province. The costs associated with the plans, which can often be a deterrent for coverage, are also presented. Lastly, we discuss the implications of the limited public drug plan coverage for research using administrative data in provinces without point-of-sale data on drugs dispensed.

Prescription drug coverage differs for each of the ten provinces in Canada because of healthcare being governed at the provincial level. Due to the disparity in drug coverage between provinces, there has been a substantial push for the development of a Canadian Pharmacare Program. Implementing a nationwide program would provide equal access to medications for all Canadians, while simultaneously increasing the nation’s overall bargaining power to leverage substantial cost savings when purchasing pharmaceuticals. Specifically, the Canadian parliamentary budget officer estimates a potential savings of $4.2 billion annually as a result of universal drug coverage in Canada.1 However, implementation of such a plan would require significant collaboration and agreement between the provincial and federal governments due to the ample differences in current provincial drug plan coverage and priorities in spending. While progress has been made in planning a Canadian Pharmacare Program, no concrete steps have been made toward its establishment. A plethora of real-world data surround prescription drug use in Canada, although the variability in prescription drug coverage across Canadian provinces adds a level of complexity to conducting research that utilizes these data from administrative healthcare datasets. For example, British Columbia, Alberta and Manitoba collect data at the pharmacy level (point-of-sale). Other provinces, such as Ontario, Quebec and Nova Scotia do not collect point-of-sale data and thus, only have data on drug claims from provincial public drug insurance plans. While some data on drug claims and basic patient demographics from private drug insurance plans, such as Telus Health Solutions, is available for real-world evidence studies, these data cannot be linked to provincial healthcare datasets. Thus, information on disease status cannot be obtained or linked to other important outcomes of prescription drug use.

Based on our findings, approximately one-third of Canadians are covered by provincial public plans for prescription drugs (36.3%), and the majority are covered by private plans (62.2%). Importantly, these estimates are not mutually exclusive as some Canadians have both public and private drug plan coverage. However, 16.5% of Canadians remain uninsured and pay out-of-pocket for prescription drugs they require. Research studies that utilize public drug coverage data alone are vulnerable to selection bias as only certain demographics are eligible for public plans in some provinces. Examples of such populations are; seniors (65 years of age and older), low-income residents or those with very serious or advanced diseases, such as cystic fibrosis, cancer or HIV/AIDS. Therefore, the population covered by the public drug plans are not representative of the entire Canadian population, which severely inhibits the ability to utilize these data in an applied manner. This discrepancy further emphasizes the need for data at the pharmacy level for research purposes, rather than relying on drug claims from provincial public plans. A Canadian Pharmacare Program would allow data on drug dispensing at the pharmacy level, provide comprehensive data (public, private and out-of-pocket payers) to be utilized for research that is representative of all Canadians, and improve personalized healthcare through research. For more information on pharmaceutical data available in each province in Canada, please see our white paper, Canadian Provincial Administrative Health Data for Research.

Read the full white paper here!