Access to diabetes medication, supplies & medical devices

Position Statement

Many Canadians rely on provincial, territorial, or federal government sponsored supplementary health plans to obtain the medications, devices and supplies they need to manage their medical conditions. Eligibility for public coverage varies across Canada, and can be based on factors such as age, income, and treatment type. Many people have access to private supplementary health plans sponsored by their employer.

People with diabetes should have timely access to medication, supplies, and medical devices that can improve their immediate quality of life and that may decrease the likelihood of future complications.

Some plans may not cover a prescribed medication or device or may impose medical criteria that are not in keeping with Diabetes Canada’s Clinical Practice Guidelines. This means people in certain provinces or territories cannot quickly or easily access the most appropriate medications for their condition.

Cost is also a barrier to access diabetes treatments and can affect people’s ability to properly manage their diabetes. The Conference Board of Canada found that about 3% of Canadians have no access to public or private coverage and that over 10% of Canadians are not enrolled in either a public or private plan in 2020.(1) Further, a Statistics Canada survey from 2021 found that one fifth of Canadians (21%) reported having no coverage for medication costs during the pandemic.(2) Even with public or private coverage, Canadians living with diabetes can pay thousands of out-of-pocket dollars annually for their medications, devices, and supplies.(3) Private group plans offer different levels of reimbursement, but not all employers provide prescription drug coverage for all diabetes medications, devices, and supplies.

Co-pays, deductibles, and premiums applied to the public and private plans may prohibit access if a person cannot afford to pay them(4). Many people have to choose between paying for food/rent/utilities and managing their diabetes. Some individuals cannot regularly fill their prescriptions while others take their medications less frequently and/or at a lower dose than indicated to extend their prescription and save money. Some must go without a prescribed insulin pump and/or a continuous glucose monitor (CGM) because costs are prohibitive.

Those who cannot afford their medications, or to take them as directed, or are not able to access the most appropriate option will often have difficulty managing their condition. These barriers to access can have very serious short and long-term health impacts and represent a burden to individuals, families, and Canadian society at large. High and unnecessary costs are incurred from lost productivity and elevated health-care system use, such as hospitalizations and ER visits, due to diabetes and its many complications.

Means Testing

Means testing is a process whereby an individual’s access to products or services is dependent on that person's financial ability to pay according to criteria set by a government. Means testing can be used to determine deductible levels, plan premiums, and program eligibility.

A supplementary health plan that uses means testing to determine eligibility for government subsidy often leaves many people with diabetes with high out of pocket costs or unable to afford to pay for the medications, supplies, and devices they need.

Copayments, Deductibles, and Premiums

Deductibles are the dollar amount that an individual or household must pay out of pocket, usually annually, on prescription drugs, supplies, and/or devices before a drug plan will begin to pay.

People enrolled in a private or public plan often struggle to afford their prescriptions because of the cost of copayments, deductibles, and premiums.

Copayments are the amount paid out of pocket by an individual each time a prescription is filled with the remainder of the cost paid by the drug plan. Copays come into effect after the deductible limit has been reached. Copayments can either be a percentage amount of the prescription cost or a fixed payment per prescription.

There is strong evidence that user fees create barriers to access. Research has shown they prevent people from taking their prescription drugs properly, or even at all. User fees are particularly hard on people with complex or chronic health problems and those with low incomes(5).

Recommendations

Diabetes Canada recommends to the federal government that universal pharmacare should:

• Emphasize comprehensiveness and choice. Align Diabetes Canada’s Clinical Practice Guidelines and develop a comprehensive federal formulary, in consultation with people with lived experience of diabetes, healthcare experts, the provinces and territories, and Indigenous communities.
• Ensure continued improvement in access and care. As outlined in Diabetes Canada Clinical Practice Guidelines, the government should adopt a principle of ‘continued improvement of care and access, reflecting the reality that new techniques and treatments will continue to become available after the pharmacare program is adopted.
• The pharmacare system must implement this principle with a mechanism to ensure improvements in care, services and products are incorporated into the system as they emerge.
• Provide robust and fulsome consultation on pharmacare. Ensure robust and fulsome consultation, including persons with lived experience of diabetes, health care providers, researchers, the provinces and territories, and Indigenous communities. This consultation should include the development of real and practical scenarios regarding the impact of the proposed pharmacare plan.

Diabetes Canada recommends that all levels of government:

• Align public drug plan policies with Diabetes Canada’s current Clinical Practice Guidelines to provide high quality treatment and optimize patient care in every jurisdiction across the country.
• Review government sponsored drug programs to remove administrative barriers (i.e. the costs associated with learning about, applying for, and using public services and benefits) to access.
• Where means testing is used or premiums, co-pays, and/or deductibles imposed, these policies should be evaluated regularly to ensure they are not barriers to access.
• Ensure people living with diabetes across Canada have access to the education and supports they require that allow them to effectively self-manage their disease.

Conclusion

Diabetes Canada supports an individualized patient-centered approach that prioritizes the needs and safety of people living with diabetes. People living with diabetes should have access to safe and effective treatment options without financial hardship. Health care providers and people with diabetes need a chance to make a joint informed decision about treatment options.

People with diabetes need timely access to medication, supplies and devices that can improve their quality of life and potentially reduce or delay the onset of serious complications. This has the potential to save the health-care systems millions of dollars by way of fewer doctor visits, medical interventions, and hospital stays.

Diabetes Canada will review this policy statement regularly, to ensure that it continues to be accurate and reflect the most up-to-date evidence.

References

1. Gagnon-Arpin, Isabelle, Wanlin Chen, and Chad Leaver. Understanding the Gap 2.0: A Pan-Canadian Analysis of Prescription Drug Insurance Coverage. Ottawa: The Conference Board of Canada, 2022.
2. Cortes, Kassandra and Leah Smith. Insights on Canadian Society: Pharmaceutical access and use during the pandemic. Ottawa: Statistics Canada, 2022.
3. Diabetes Canada. Diabetes and Diabetes- Related Out-of-Pocket Costs: 2022 Update. Ottawa: Diabetes Canada; 2022.
4. Clement, F., & Memedovich, K. A. (2018). Drug coverage in Canada: gaps and opportunities. Journal of psychiatry & neuroscience : JPN, 43(3), 148–150. https://doi.org/10.1503/jpn.180051
5. Rättö, Hanna & Aaltonen, Katri. (2021). The effect of pharmaceutical co-payment increase on the use of social assistance-A natural experiment study. PloS one. 16. e0250305. 10.1371/journal.pone.0250305.

Last Updated: June 2024