Pharmacare Rollout in Canada Faces Criticism Amid Coverage Gaps

The recent implementation of federal pharmacare in **Manitoba** and **Prince Edward Island** has raised concerns about its effectiveness in providing universal drug coverage. Instead of addressing existing gaps, the program appears to be creating new challenges for patients. According to the **Canadian Health & Life Insurance Association**, approximately **75 percent** of Canadians already receive prescription drug coverage through employer-sponsored plans. Polls indicate a significant portion of the population is apprehensive about the federal program disrupting their current coverage.

Eddie’s experience, though a pseudonym for privacy, exemplifies the issues faced under the new pharmacare system. For years, he relied on metformin to manage his **Type-2 diabetes**, a medication that costs between **$10 and $20** monthly, typically covered by his private plan. However, when Manitoba rolled out its pharmacare program on **April 15, 2023**, the provincial plan took over coverage for metformin, leading to unintended consequences.

Following the transition, Eddie’s doctor recommended an additional medication to help regulate his blood sugar. Priced at around **$500** per month, Eddie discovered that this essential drug was not included on pharmacare’s list of eligible medications and thus was not covered. To complicate matters further, his private insurance also denied coverage for the new medication, as Eddie’s file no longer reflected his metformin prescription after the pharmacare takeover.

The adjudication systems of many private insurers rely on established clinical guidelines, which indicate that the new medication should be prescribed alongside metformin. However, the absence of metformin in Eddie’s records led to confusion and denial of coverage. Fortunately, with assistance from his pharmacist and physician, he navigated the complex paperwork to secure the necessary coverage from his private plan. This stressful experience prompted Eddie to reach out to **Diabetes Canada** to report the issue.

The situation raises critical questions about how many others, like Eddie, have faced similar challenges. Many patients may be unaware that their private plans could still cover medications omitted from the pharmacare list. Others might feel overwhelmed by the bureaucratic process and may abandon their efforts altogether. Prior to the implementation of federal pharmacare, numerous Canadians with diabetes were already struggling to afford their prescriptions or were forced to ration their medications.

The implications of these coverage gaps are particularly severe for individuals needing comprehensive treatment. Barriers to access can lead to increased hospitalization risks and other significant health consequences. Pharmacy owners in **Manitoba** and **Prince Edward Island** have reported numerous instances where coverage has been denied, delayed, or rescinded due to the lack of clarity in pharmacare’s integration with existing private plans. These outcomes contradict the original intentions behind the establishment of a universal pharmacare program.

To resolve these issues, a fundamental reassessment of the pharmacare model is necessary. The **Pharmacare Act**, which proposes a “single-payer, first-dollar coverage” approach, cannot be successful without effective coordination with private insurance plans or a broader list of covered medications. It is crucial to enhance the current mixed-payer system rather than hastily expanding the federal program.

Before any further discussions on expanding pharmacare take place, it is vital to learn from the experiences of individuals like Eddie. The disruption in his coverage not only hindered his access to medication but also posed risks to his health. Provinces should carefully weigh the implications of adopting a model that has yet to prove effective. Ensuring that no more individuals fall through the cracks must take precedence.

Shelita Dattani, a pharmacist and senior vice-president of pharmacy affairs and strategic engagement at the **Neighbourhood Pharmacy Association of Canada**, emphasizes the importance of reevaluating how pharmacare is implemented to better serve the Canadian population.