The Reimbursement Landscape: The Canada Health Act

The five criteria of the Canada Health Act are:

• Public Administration: the administration of the health care insurance plan of a province or territory must be carried out on a non-profit basis by a public authority;
• Comprehensiveness: all medically necessary services provided by hospitals and doctors must be insured;
• Universality: all insured persons in the province or territory must be entitled to public health insurance coverage on uniform terms and conditions;
• Portability: coverage for insured services must be maintained when an insured person moves or travels within Canada or travels outside the country; and
• Accessibility: reasonable access by insured persons to medically necessary hospital and physician services must be unimpeded by financial or other barriers.

Only pharmaceuticals administered in hospitals are subject to the criteria of the Canada Health Act. As a result, private insurers and public drug plans reimburse close to 90% of all prescription drugs dispensed in Canada. Reimbursement is contingent on a positive review of reimbursement submissions filed with private and public managed formularies.

Click here for a Glossary of Drug Plan Terms.