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Visions Journal

A reminder that this article from our magazine Visions was published more than 1 year ago. It is here for reference only. Some information in it may no longer be current. It also represents the point of the view of the author only. See the author box at the bottom of the article for more about the contributor.

I Can’t Access or Afford the Medication I Need: Now What?

Government programs are there to help . . .

Megan Dumas

Reprinted from "Medications" issue of Visions Journal, 2007, 4 (2) pp. 33-35

It’s no secret that the health care system isn’t always easy to figure out. People don’t usually try to make sense of the system until they really need it. By then, an individual or their loved one is sick, and the last thing they feel like doing is focusing energy on looking up government programs.

As someone living in BC and in no way affiliated with the government, I thought I’d explain the programs as best I can. I’ve summarized information that I found on the various program websites.

Province of BC—helping with costs

Living with a mental illness can be hard, not only mentally and physically, but financially as well. And prescriptions can be pricey. The provincial government has several programs that can help ease financial concerns.

PharmaCare–Made up of a number of programs that lower the cost of prescription medications for people living in BC who are registered with the Medical Services Plan.* Two of these programs are Fair PharmaCare and Plan G.

  • Fair Pharmacare–Assists low-income households by paying all, or a portion of, their prescription medication expenses. Depending on your household net income, you may have to pay the full cost of your family’s medications until a certain amount is spent (this amount is called your deductable). After the deductable amount has been used up by your household, the government will then pay 70% of your medication expenses. And, if you spend more than a certain percentage of your income on medications, the government may pay the entire cost of your family’s medications for the remainder of the year. For more information about Fair Pharmacare, visit www.health.gov.bc.ca/pharme.

  • Plan G–Pays for the entire cost of psychiatric medications based on your income and clinical need. Plan G is also known as the No-Charge Psychiatric Medication Plan. For more information on this program, see Daryn’s article on the previous page.

For more information on PharmaCare, see www.health.gov.bc.ca/pharme/generalinfo/generalinfoindex.html.

Provincial and federal programs—helping with access and costs

Two programs exist to help you access medications that you may not be able get otherwise: BC’s PharmaCare Special Authority program and Health Canada’s Special Access Program.

PharmaCare Special Authority

You go to the pharmacy with your prescription, only to be told that PharmaCare doesn’t cover the cost of your medication, even if you’ve reached your deductable. Plan G doesn’t cover it either. But it’s so expensive!

Why won’t PharmaCare or Plan G pay for your medication? These programs cover most prescriptions, but not certain “limited coverage” medications (see sidebar below). They may not cover your prescription if:

  • a less expensive, generic drug has the same chemical makeup as a brand name one

  • the medication is too expensive to be considered a first option for treatment

Mental health medications that need special authority/approval for coverage7

generic drug name

brand name

bupropion (an antidepressant)

Wellbutrin, Wellbutrin SR, Wellbutrin XL

clobazam (an antianxiety medication)

Frisium

cyproterone (reduces aggressive sexual drive)

Androcur, Cyprostat, and others

gabapentin (an anticonvulsant used off-label† for bipolar disorder)

Neurontin

hydroxyzine (an antianxiety medication)

Atarax, Vistaril

lamotrigine (an anticonvulsant and mood stabilizer)

Lamictal

leuprolide (reduces aggressive sexual drive)

Lupron

olanzapine (an antipsychotic)

Zydis, Zyprexa

risperidone (an antipsychotic)

Risperdal

verapamil (a mood stabilizer

Calan, Covera-HS, Isoptin, Isoptin SR, Verelan, Verelan PM

zopiclone (a sleeping aid)

Lunesta

zuclopenthixol (an antipsychotic

Acuphase, Cisordinol, Clopixol

 

The provincial government, however, does have a program under PharmaCare that may provide financial assistance for limited coverage drugs. It’s called the Special Authority program.1 If you are allergic to the generic brand of a drug, or all other cheaper treatment options have failed to work for you, and your doctor has prescribed a limited coverage medication, you can apply to the Special Authority program for assistance. This program also gives pharmacies and hospitals permission to dispense medications free of charge.

 

Each limited coverage medication has its own set of conditions that must be met in order to qualify for coverage. These conditions can include certain diagnoses, for example, or that the patient has tried certain other medications and they didn’t help. Although each drug has a different length of time it will be approved for, most mental health medications are approved indefinitely.

If your application is approved, and you are registered under Fair PharmaCare, you will receive the same amount of coverage that you do under Fair Pharmacare.2 If you are covered by Plan G and the

Special Authority application is approved, 100% of the cost of the medication will be covered.2
Those who do not qualify for Fair Pharmacare or Plan G, but have medical benefits through work or through a family member’s work, often have to apply for special authority.3 This is because many insurance companies that provide workplace benefits cover only the same medications PharmaCare does.3

Not all drugs are eligible for Special Authority. Some that aren’t include:4

  • drugs that are part of a private clinical trial

  • smoking cessation aids

  • diet therapy drugs

  • drugs classified as or used for cosmetic purposes

  • new drugs under review by PharmaCare

To apply for Special Authority, have your doctor fill out and fax in a Special Authority form. Forms are available online at www.health.gov.bc.ca/pharme/sa/criteria/mentalhealth/mentaltable.html.

Health Canada Special Access Program

You are diagnosed with a mental illness. You and your doctor start to explore different treatments, including medication. Through a painstaking process of trial and error, you try all of the available medications for your condition, but nothing seems to be working. Your condition is getting worse and is becoming very serious.

One night, you turn on the TV and see a commercial for a new drug used to treat your condition. Excited, you call your doctor, only to find out that this new medication isn’t available in Canada. The commercial was from the US, and the Food and Drug Administration has already approved sale of the drug in that country.

Why isn’t this drug available in Canada? Because Health Canada hasn’t approved it yet.
So, if you find yourself in this situation, is there anything you can do about it? Yes, if your condition is extremely serious or life-threatening, there is something you can do. Health Canada has a special program called the Health Canada Special Access Program (SAP). You can apply to SAP for access to a drug not yet available in Canada.

If you have tried everything available, or can’t try everything available because you are allergic to one of the compounds, your doctor can apply on your behalf to have the drug approved just for you. Your doctor needs to show that you have an extreme need for this medication because you are out of other options.

If the medication is approved, it must be administered by your doctor or a hospital. Retail pharmacies are not allowed to distribute this special medication. Access to the medication is only given for six months, and then your doctor must reapply.

“Intractable depression” is listed on the Health Canada website as one of the conditions that may qualify under SAP.5 Your doctor must provide evidence that your depression is intractable.

If you feel as though you’ve run out of options, talk to your doctor. The application forms for the Special Access Program, and tips for your doctor on how to fill the forms out can be found at www.hc-sc.gc.ca/dhp-mps/acces/drugs-drogues/index_e.html.

For more information about SAP, phone 613-941-2108 (in Ottawa) or e-mail [email protected].

 
About the author
Megan is a Communications Officer at the Canadian Mental Health Association, BC Division, and Editorial Assistant for Visions.
*Medical Services Plan:

Provides financial coverage of basic medical services for British Columbians. There is a monthly premium (fee) charged for this coverage. Premiums are charged according to the size of your family. To learn about the benefits provided by MSP, visit www.health.gov.bc.ca/msp/infoben/benefits.html.There is a program in place called Premium Assistance that helps families pay their monthly MSP premiums, depending on financial need. If your family receives full and partial premium assistance, you may be eligible for additional health care services through the Healthy Kids program of the Ministry of Employment and Income Assistance. For more information on premium assistance, visit www.health.gov.bc.ca/msp/infoben/premium.html#assistance.

Footnotes:
  1. Unless otherwise noted, all information regarding the Special Authority program was adapted from the program website, or from documents found on that website, at www.health.gov.bc.ca/pharme/sa/saindex.html.

  2. Phone interview with Plan G representative (no name given), 12:32 p.m., December 17, 2007.

  3. Phone interview with PharamaCare Help Desk representative (no name given), 11:37 a.m., December 17, 2007.

  4. www.health.gov.bc.ca/pharme/sa/sa1answer.html.

  5. Special Access Program information was adapted from the Special Access Programme – Drugs (frequently asked questions) webpage at www.hc-sc.gc.ca/dhp-mps/acces/drugs-drogues/sapfs_pasfd_2002_e.html. NOTE: This article is based on information available as of December 2007. Changes in some government programs are expected in 2008.

  6. Lexchin, J. (2006). A comparison of new drug availability in Canada and the United States and potential therapeutic implications of differences. Health Policy, 79(2-3), 214-220.

  7. www.health.gov.bc.ca/pharme/sa/criteria/mentalhealth/mentaltable.html.

 

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