The Personal Health Navigator is available to all Canadian patients. Questions about your doctor, hospital or how to navigate the health care system can be sent to AskPaul@Sunnybrook.ca
The Question: My wife was recently diagnosed with breast cancer. We are both self-employed. So we don’t have drug insurance coverage through a workplace. We’re worried about how much we may have to pay for cancer medications. I hear they can be really expensive. What are our options?
The Answer: I can tell from your question that you are already well-informed about one of the major shortcomings of the Canadian health-care system: Medicare will pay for doctor visits and medically-necessary treatments received inside a hospital, but it doesn’t necessarily cover the cost of medications administered outside a hospital like a cancer pill you pop in your mouth at home.
Many people are “shocked and upset” to discover they may have to pay out of pocket for their cancer medications that can cost thousands of dollars, says Manisha Gandhi, manager of the patient and family support program at Sunnybrook Health Sciences Centre.
She notes that physicians, nurses and other specialists are extremely mindful of the fact that the cost of treatment can impose a financial hardship on some patients and their families.
Your wife will likely be asked if she has private insurance. And I expect a member of her cancer-treatment team will point you in the direction of where your family might be able to get financial aid.
A growing number of cancer centres – including Sunnybrook – now have specialized staff to help patients deal with drug reimbursement issues.
“Since we know that patients and their families are going through a lot, we try to smooth out the process as best we can,” said Ms. Gandhi.
But even without such a specialist, your cancer team should be able to put you in touch with a pharmacist, pharmacy technician or social worker who can provide some guidance.
It’s important to know that most Canadian provinces and territories have some form of assistance for patients facing huge drug costs, although the level of aid varies considerably across the country.
(Seniors and those on social assistance get automatic drug coverage, but not all medications are included on a province’s formulary, or list, of approved drugs. So a senior could still be facing a big bill for a relatively new and pricey cancer medication.)
In Ontario, people who have high prescription drug costs relative to their household income can apply to the Trillium Drug Program. Once you qualify, and if the drug is listed on the provincial formulary, you will still be expected to pay a portion of the drug costs. For most people, it equals about 4 per cent of their household’s total net income.
“You will have a deductible based on your income which means you are buying drugs up to a certain dollar amount, and after that the costs will be covered,” explained Alison Chambers, a drug reimbursement specialist at Sunnybrook.
She pointed out that many people with private insurance are also required to pay a deductible or make a co-payment and there may be a cap on the total payout.
By contrast, some provinces – such as British Columbia, Alberta and Saskatchewan – will pick up 100 per cent of the cost of the cancer drugs listed on their formularies – regardless of whether the medications are administered intravenously in a hospital or taken in pill form at home.
In a few special circumstances, pharmaceutical companies will offer price breaks to those in need. A hospital pharmacy team member or a drug reimbursement specialist may be able to help you apply for these programs.
Overall, how much people end up paying for essential cancer drugs depends on where they live, the terms of their private insurance (if they have any) and the specific medications they are prescribed.
“When it comes to reimbursement, it varies case by case,” said Ms. Chambers. And, unfortunately, some people face onerous costs.
Leading medical organizations and patient groups, including the Canadian Cancer Society, have called for a uniform national catastrophic drug plan that would kick in when medication costs exceed a certain level of a patient’s household income.
Many provincial and federal politicians have voiced support for such a program, although there’s no agreement about who would pay for it. In the meantime, some patients and their families are forced to make difficult choices.
Be sure to reach out to your wife’s health-care team for financial advice and any other issues that arise in the course of her treatment. People may not realize the range of services available to them.
If you want to know which cancer drugs are covered under the various provincial programs you can check out a website developed by Dr. Kong Khoo, vice-chair of the Cancer Advocacy Coalition of Canada.
Reimbursement information for a broader range of prescription medications can be found here.
Paul Taylor is Sunnybrook’s Patient Navigation Advisor. His column Personal Health Navigator provides advice and answers questions from patients and their families, relying heavily on medical and health experts. His blog is reprinted on healthydebate.ca with the kind permission of Sunnybrook Health Sciences Centre. Email your questions to AskPaul@sunnybrook.ca