Seniors Pharmacare or Private Health Insurance

What is Pharmacare?

Broadly, Pharmacare is an insurance program to help eligible Canadians with the cost of prescription medication. There is a National Pharmacare Plan in the making, that aims to be available by March 2026.

In its first iteration, the National Pharmacare Plan will cover diabetes medications like Metformin and Insulin, and a range of contraceptives such as birth control pills, IUDs, and injections.

Who is eligible for national Pharmacare?

Because the provinces and territories currently manage healthcare, the federal government is working with each of them individually to reach agreements on providing this additional coverage. To start, only 3 provinces and 1 territory will be covered:

Prince Edward Island
Manitoba
British Columbia
Yukon

Provincial Pharmacare

Until the National Pharmacare plan is truly a national plan, each province provides pharmacare to its residents, to some degree. These plans are primarily for seniors, although some provinces extend to youth and low income residents.

Details vary from province to province, so we encourage you to consult them directly (There are links at the bottom of this article). At the time of writing, these are common eligibility requirements:

Be a resident of that province
Be aged 65 or over
Have a valid provincial Health Card
Have no coverage for prescription drugs under another insurance plan

Enrolling in the program

In most provinces and territories, seniors need to enrol in the program. Many provinces, like Nova Scotia and New Brunswick, will mail you program information and an enrolment package before your 65th birthday.

In a few provinces, like Prince Edward Island, a drug card is sent to you automatically when you turn 65 and start to receive Federal Guaranteed Income Supplement (GIS) and Old Age Security (OAS).

What’s covered by provincial Pharmacare

The Seniors’ Pharmacare Programs pay for some drugs, devices and medical supplies. You can find a full list of what’s covered in each province’s formulary; there are links at the end. (A formulary is a massive list intended for physicians. It’s easiest to download the list and then search for the name of your medication or device.) Regardless of the drug or province:

Both generic and brand name drugs may be covered.
Some medical supplies are covered, including those for diabetes, ostomy, and prostheses.
They must be prescribed by a licensed healthcare professional, such as a doctor, dentist, pharmacist, midwife, optometrist or nurse practitioner.
The prescription must be filled at a pharmacy in your province.

What does Pharmacare cost?

Again, this varies by province. There may be an annual premium, or cost-sharing (co-pay), or a deductible. In spite of the costs, these programs still offer significant savings, especially as the need for prescription medication tends to increase as we get older.

Can you have private health insurance too?

As mentioned above, most provinces won’t provide Pharmacare to you if you have other coverage in place. This might be a group plan through work, or personal private health insurance.

Some provinces, like NL and PEI, describe their program as a last resort plan. This means that the province will pay when no other third parties will. So you could have private insurance in place, and if they won’t pay and the medication is listed on the provincial formulary, they will.

Is it best to have Pharmacare or private health insurance?

For the most part, these Pharmacare programs only cover prescription drugs. The decision should be based on your unique situation. Here are a few considerations:

Are you or your spouse currently on medications and what is their cost?
Do you have pre-existing conditions? Does your spouse?
How old is your spouse when you turn 65?
If your employer benefits expire when you turn 65, what happens to your spouse’s coverage?
Do you currently have dental, physio, vision or other healthcare needs?

Perhaps your spouse is a better fit for private insurance. Maybe your medications aren’t covered in your province’s formulary. Maybe you are both in excellent health at the moment.

It’s a comfort to know that most seniors will be eligible for drug benefits offered by their province, for little cost. But prescriptions are a fraction of potential health care expenses. So for most seniors, integration of private insurance with a government drug plan is a reasonable strategy. However, understanding the complexities and fine print requires expertise. It’s also a good idea to not wait until you’re 65 to sort out. Planning health insurance before you retire can be an integral part of your financial plan.

Learn more about private health insurance options available to you. Don’t hesitate to get in touch with one of our advisors to help navigate these important decisions.

Pharmacare resources for your province:

Provincial regulations and legislation may have changed since the time of writing. Your province’s website is the most accurate source of information.