A-29.01, r. 4 - Regulation respecting the basic prescription drug insurance plan

Updated to 5 January 2014

This document has official status.

chapter A-29.01, r. 4

Regulation respecting the basic prescription drug insurance plan

Act respecting prescription drug insurance

(chapter A-29.01, ss. 19, 78, 112, 113 and 116).

The fees prescribed in the Regulation have been indexed as of 1 July 2013 pursuant to the notice published in Part 1 (French) of the Gazette officielle du Québec of 29 June 2013, page 749.

As of 1 July 2013, the annual premium will be increased by 4.8% resulting in the maximum amount of the annual premium being set at $607.

The deductible and maximum annual contribution amounts and the coinsurance percentage have not been revised.

DIVISION I COVERAGE EQUIVALENT TO THE BASIC PRESCRIPTION DRUG INSURANCE PLAN COVERAGE

1. The following classes of persons are entitled to coverage equivalent to the coverage of the basic plan established by the Act respecting prescription drug insurance (chapter A-29.01) under another Act of Québec or under a program administered by a government or by a government department or body but are not covered by this plan:

(1)  beneficiaries of the “Agreement” within the meaning of the Act approving the Agreement concerning James Bay and Northern Québec (chapter C-67) and the Act approving the Northeastern Québec Agreement (chapter C-67.1);

(2)  users or beneficiaries sheltered in a facility maintained by a public or private institution under agreement operating a residential and long-term care centre governed by the Act respecting health services and social services (chapter S-4.2) or by the Act respecting health services and social services for Cree Native persons (chapter S-5);

(3)  Indians registered with the Department of Indian Affairs and Northern Development of the Government of Canada in accordance with the Indian Act (R.S.C. 1985, c. I-5) and Inuit recognized by that department.

O.C. 1519-96, s. 1; O.C. 973-97, s. 1.

DIVISION II COVERAGE UNDER THE BASIC PRESCRIPTION DRUG INSURANCE PLAN

§ 1 . — Coverage of pharmaceutical services

2. In addition to the cost of the services rendered to fill or renew a prescription, the following pharmaceutical services are covered under the basic prescription drug insurance plan for which the Régie de l’assurance maladie du Québec provides coverage, in accordance with section 22 of the Act respecting prescription drug insurance (chapter A-29.01):

(1)  refusal to fill or renew a prescription;

(2)  a pharmaceutical opinion, that is, the reasoned opinion of a pharmacist on the pharmacological and therapeutic history of an eligible person drawn up under the authority of that pharmacist or on the therapeutic value of one or a combination of treatments prescribed, given in writing to the prescriber.

O.C. 1519-96, s. 2.

§ 1.1 . —

(Replaced)

O.C. 364-97, s. 1; M.O. 99-09-29, s. 1.

2.1. (Replaced).

O.C. 1532-96, s. 1; O.C. 431-97, ss. 1 and 2; O.C. 776-97, s. 1; O.C. 1217-97, s. 1; O.C. 1709-97, s. 1; O.C. 391-98, s. 1; O.C. 834-98, s. 1; O.C. 1189-98, s. 1; O.C. 9-99, s. 1; O.C. 274-99, s. 1; O.C. 781-99, s. 1; M.O. 99-09-29, s. 1.

§ 2 . — Medications provided as part of the services provided by an institution

3. The medications entered on the List of medications drawn up by the Minister of Health and Social Services under section 60 of the Act are part of the coverage under the basic plan referred to in the third paragraph of section 8 of the Act where they are provided by an institution referred to in the Regulation made under paragraph b of section 37 of the Pharmacy Act (chapter P-10) to persons other than the persons admitted to or registered at that institution.

Coverage of the cost of medications in accordance with the prices determined in accordance with the terms and conditions established in the list of medications for institutions governed by the Act respecting health services and social services (chapter S-4.2) or by the Act respecting health services and social services for Cree Native persons (chapter S-5).

O.C. 1519-96, s. 3.

DIVISION III EXEMPTION FROM PAYMENT OF PREMIUM

4. Any eligible person referred to in section 15 of the Act respecting prescription drug insurance (chapter A-29.01) shall be exempted from payment of the premium during an entire calendar year where he remains outside Québec for that entire year and shall retain his status as resident of Québec under the Health Insurance Act (chapter A-29), provided that he notifies the Board of his absence from Québec.

O.C. 1519-96, s. 4.

DIVISION IV FUNCTIONAL IMPAIRMENTS

5. For the purposes of section 17 of the Act respecting prescription drug insurance (chapter A-29.01), the following are the functional impairments from which an eligible person may suffer:

(1)  an intellectual impairment, with an intelligence quotient or a development quotient of less than 70, as demonstrated in an evaluation using standardized tests; the development quotient is determined by multiplying by 100 the ratio between the person’s developmental age and his chronological age;

(2)  a severe, permanent psychiatric, organic or motor impairment which, despite technological assistance in the case of a motor impairment, considerably hinders the person in carrying out normal day-to-day activities and compromises his social integration;

(3)  a severe, permanent multiple impairment, with 2 or more of the following impairments the combination of which considerably hinders the person in carrying out normal day-to-day activities and compromises his social integration:

(a)  an intellectual impairment;

(b)  a psychiatric impairment;

(c)  an organic impairment;

(d)  a motor impairment;

(e)  a speech and language impairment;

(f)  a hearing impairment for which an audiometric evaluation, before correction, indicates an average acuity threshold of 40 dB or more at a frequency of 500, 1,000 and 2,000 hertz in the ear having the greater hearing capability;

(g)  a visual impairment which, after correction by means of appropriate ophthalmic lenses, is characterized by visual acuity in each eye of not more than 6/21 or by a field of vision in each eye that is less than 60° in the 180° and 90° meridians or that requires the use of special optical systems of over +4.00 dioptres.

O.C. 1519-96, s. 5.

6. The functional impairment described in paragraph 1 of section 5 shall be stated in an attestation containing the results obtained and issued by a person authorized to carry out such evaluations. The impairments described in paragraphs 2 and 3 of that section shall be stated in a medical certificate issued by a physician.

The attestation or the medical certificate shall be submitted to the Board and, where applicable, on request, to the insurer or to the administrator of an employee benefit plan.

O.C. 1519-96, s. 6.

DIVISION IV.1 PREMIUM AND CONTRIBUTION

O.C. 1405-2000, s. 1; O.C. 620-2003, s. 1.

6.1. The rules pursuant to which the Board, in accordance with section 28.1 of the Act respecting prescription drug insurance (chapter A-29.01), shall fix annually the rate of adjustment of the maximum amount of the annual premium are as follows:

(1)  the amount of the annual premium shall be adjusted on 1 July, on the basis of the experience of the months of April to March of the preceding fiscal year, taking into account the increase in the costs of the plan to persons referred to in paragraph 4 of section 15 of the Act respecting prescription drug insurance;

(2)  the adjustment shall take into account, on the same basis, the anticipated cost of changes to coverage under the plan, particularly the cost of adding new medications to the List of medications;

(3)  the adjustment shall also take into account any other factor having a direct effect on the cost of the plan.

O.C. 1405-2000, s. 1; O.C. 620-2003, s. 2.

6.2. The rules pursuant to which the Board, in accordance with sections 13.1 and 28.1 of the Act respecting prescription drug insurance (chapter A-29.01), fixes annually the rates of adjustment of the deductible amount, of the coinsurance and of the maximum annual contribution, and the classes of persons to which they apply are as follows:

(1)  for persons referred to in the first and second paragraphs of section 28 of the Act respecting prescription drug insurance, the deductible amount, the coinsurance and the maximum annual contribution are adjusted on 1 July, so as to allow for the proportion of the gross costs assumed by those classes of persons to be maintained, on the basis of the experience of the months of April to March of the preceding fiscal year, taking into account the increase in the costs of the plan to those persons;

(2)  in the application of the paragraph 1, however, the rate of adjustment of the maximum contribution may not exceed

(a)  the rate of increase in the Pension Index, established under the Act respecting the Québec Pension Plan (chapter R-9) and that applies on 1 January of the year of the adjustment, reduced by 0.5%, in regard to the persons referred to in the first paragraph of section 28 of the Act respecting prescription drug insurance;

(b)  the rate of increase in the Pension Index, established under the Act respecting the Québec Pension Plan and that applies on 1 January of the year of the adjustment, increased by 0.5%, in regard to the persons referred to in the second paragraph of section 28 of the Act respecting prescription drug insurance.

O.C. 620-2003, s. 3.

DIVISION V REGISTRATION

7. Every person to whom paragraph 4 of section 15 of the Act respecting prescription drug insurance (chapter A-29.01) applies shall, to register in the basic prescription drug insurance plan, provide the Board with the following information:

(1)  his full name;

(2)  his sex;

(3)  his date of birth;

(4)  his health insurance number;

(5)  his social insurance number, where applicable;

(6)  his home address;

(6.1)  his employment status, the name of his employer, and his profession or habitual occupation;

(7)  in the case of a person referred to in the second paragraph of section 11, a statement according to which the group insurance contract or the employee benefit plan to which he is required to become a member on the basis of current or former employment status, profession or habitual occupation is applicable solely outside Québec;

(8)  a statement according to which he is not required to become a member of a group insurance contract or an employee benefit plan applicable to a group of persons determined on the basis of current or former employment status, profession or habitual occupation;

(9)  his civil status, whether he is single, married a common-law spouse, separated, divorced, widowed or a member of a religious order;

(9.1)  the employment status, the name of the employer, the profession or habitual occupation of his spouse, where applicable, and if the latter is not entered on the form of the person who registers, the spouse’s full name, date of birth and health insurance number;

(10)  a statement according to which his spouse is not obliged to ensure his coverage as a beneficiary taking into account that he is not himself required to become a member of a group insurance contract or an employee benefit plan applicable to a group of persons determined on the basis of current or former employment status, profession or habitual occupation, where applicable;

(11)  in the case of a person under 18 years of age, a statement according to which he is emancipated and the reason of the emancipation;

(12)  in the case of a person of 25 years of age or under who is duly registered as a student, a statement according to which he attends an educational institution on a part-time basis or that he has a spouse.

O.C. 1519-96, s. 7; O.C. 582-97, s. 1.

8. Every person to whom paragraphs 1, 3 and 4 of section 15 of the Act apply shall, to register his child or a person suffering from a functional impairment and domiciled with him in the basic prescription drug insurance plan, provide the Board with the following information in respect of each person that he must register in accordance with section 20 of the Act:

(1)  his full name;

(2)  his sex;

(3)  his date of birth;

(4)  his health insurance number;

(5)  his social insurance number, where applicable;

(6)  his home address;

(7)  in what capacity, father, mother or tutor, he is registering the child or the person suffering from a functional impairment;

(8)  his civil status, whether he is single, married, a common-law spouse, separated, divorced, widowed or a member of a religious order;

(9)  in the case of a child under 18 years of age, a statement according to which his child is not emancipated;

(10)  in the case of a child 25 years of age or under;

(a)  a statement that the child is spouseless and pursues full-time studies, within the meaning of section 9 of the Act respecting financial assistance for students (chapter A-13.3), as a duly registered student in an educational institution; or

(b)  a statement that the child is spouseless, suffers from one of the impairments provided for in paragraphs 1 to 4 of section 11.1 and pursues part-time studies, within the meaning of section 9 of the Act respecting financial assistance for students, as a duly registered student in an educational institution;

(11)  in the case of a spouseless person suffering from a functional impairment, a statement according to which the person is a person of full age, that the impairment occurred before he reached the age of 18, that he receives no benefits under the last resort financial assistance program provided for in the Individual and Family Assistance Act (chapter A-13.1.1) and that he is domiciled with that person;

(12)  a statement according to which neither he, nor his spouse, nor any other person referred to in section 18 of the Act respecting prescription drug insurance (chapter A-29.01) must ensure coverage for that child or the person suffering from a functional impairment that is domiciled with him and in respect of whom an application for registration is made taking into account that neither one nor the other is required to become a member of a group insurance contract or an employee benefit plan applicable to a group of persons determined on the basis of current or former employment status, profession or habitual occupation, where applicable.

Furthemore, the person shall provide the Board with the following documents:

(1)  in the case referred to in clause b of subparagraph 10 of the first paragraph and subject to the third paragraph of section 11.2, the medical certificate and the evaluation of disabilities provided for in the first and second paragraphs of that section;

(2)  in the case referred to in paragraph 11 of the first paragraph, the attestation of results or the medical certificated provided for in section 6.

Notwithstanding the foregoing, in the case of a birth that occurred in Québec, the father or mother who declares the birth of a child to the registrar of civil status in accordance with article 113 of the Civil Code shall be deemed to have made an application for the registration of that child in the basic prescription drug insurance plan with the Board where that person is a person to whom paragraphs 1, 3 or 4 of section 15 of the Act respecting prescription drug insurance apply and that he is registered himself.

O.C. 1519-96, s. 8; O.C. 364-97, s. 2.

8.1. Any person referred to in the first paragraph of section 19 or in section 20 of the Act shall notify the Board of any change in the information or documents forwarded under sections 7, 8 and 11.2 of this Regulation, within 30 days of such a change.

O.C. 364-97, s. 3.

DIVISION VI TRANSITIONAL PROVISIONS

9. Notwithstanding section 5 of the Act, any person who settles in another Canadian province shall cease to be a person eligible for the basic prescription drug insurance plan from the day of his settlement in that other province.

O.C. 1519-96, s. 9.

10. Notwithstanding section 5 of the Act, any person legally authorized to remain in Canada and who settles in Québec shall become a person eligible for the basic prescription drug insurance plan as soon as he or his family receives benefits under the last resort financial assistance program pursuant to the Individual and Family Assistance Act (chapter A-13.1.1) and holds a valid claim booklet issued by the Minister of Income Security pursuant to section 70 of the Health Insurance Act (chapter A-29).

O.C. 1519-96, s. 10.

10.1. The Public Service Health Care Plan is deemed to include at least the basic coverage of the prescription drug insurance plan, where an eligible person is required to become a member on the basis of current or former employment.

O.C. 582-97, s. 2; O.C. 1473-98, s. 1.

11. Any group insurance contract or employee benefit plan applicable solely outside Québec is deemed to include at least the coverage of the basic prescription drug insurance plan, where the eligible person is required to become a member on the basis of current or former employment status, profession or habitual occupation.

However, that person may register in the basic prescription drug insurance plan in accordance with section 7, if he may not otherwise benefit from drug insurance coverage as a beneficiary of the group insurance contract or employee benefit plan of an eligible person referred to in section 18 of the Act respecting prescription drug insurance (chapter A-29.01). He is then presumed not to benefit from the coverage provided for by the basic prescription drug insurance plan, pursuant to his group insurance contract or his employment benefit plan.

O.C. 1519-96, s. 11.

11.1. Any eligible person without a spouse who is 25 years of age or under, in respect of whom someone would exercise parental authority if the person were a minor, is deemed to attend an educational institution on a full-time basis if the person suffers from one of the following impairments and, for that reason, attends such institution on a part-time basis as a duly registered student:

(1)  severe visual impairment: visual acuity in each eye, after correction by means of appropriate ophthalmic lenses, excluding special optical systems and additions greater than 4.00 dioptres, is not more than 6/21, or the field of vision in each eye is less than 60° in the 180° and 90° meridians, and, in either case, the person is unable to read, write or move about in an unfamiliar environment;

(2)  severe hearing impairment: the ear having the greater hearing capability is affected by a hearing impairment evaluated, according to 1992 standard S3.21 of the American National Standard Institute, to be an average of at least 70 dB, in aerial conduction, on any of the 500, 1,000 or 2,000 Hertzian frequencies;

(3)  motor impairments, where they result in significant and persistent limitations for the student in the performance of his daily activities: loss, malformation or abnormality in the skeletal, muscular or neurological systems responsible for body motion;

(4)  organic impairments, where they result in significant and persistent limitations for the student in the performance of his daily activities: disorder or abnormality in the internal organs forming part of the cardiorespiratory, gastrointestinal and endocrinal systems.

O.C. 364-97, s. 4.

11.2. The impairments referred to in section 11.1 shall be stated in a medical certificate issued by a physician.

The disabilities related to one of those impairments shall be evaluated by a therapist specializing in the field of the impairment. In the absence of a specialized therapist or where care by such therapist is not required, such evaluation shall be made by a physician.

Where the Minister of Higher Education, Research, Science and Technology has taken into account, for the purposes of the program it administers, a medical certificate attesting that a student suffers from a major functional deficiency within the meaning of the Regulation respecting financial assistance for students (c, A-13.3, r. 1) as it reads when it is applied, such student does not have to provide the documents required under the first and second paragraphs if he provides either the Board, the group insurer or the manager of the employee benefit plan offering him coverage, a written consent authorizing him to obtain confirmation of his state from the Ministère de l’Enseignement supérieur, de la Recherche, de la Science et de la Technologie.

O.C. 364-97, s. 4; S.Q. 2013, c. 28, s. 204.

11.3. Notwithstanding section 18 of the Act respecting prescription drug insurance (chapter A-29.01), an eligible person referred to in that section shall ensure that coverage is provided to his child and spouse as beneficiaries under the group insurance contract or employee benefit plan applicable to a given group of persons of which he is a member by reason of current or former employment, profession or any other habitual occupation, only if those persons are domiciled with him.

O.C. 582-97, s. 3.

12. (Revoked).

O.C. 1519-96, s. 12; O.C. 973-97, s. 2.

13. (Revoked).

O.C. 1519-96, s. 13; O.C. 973-97, s. 2.

14. A pharmacist shall remit to any beneficiary to whom he has provided pharmaceutical services and medications the coverage of which is paid by the Board, a receipt indicating, in particular, the following information with respect to each medication thus provided:

(1)  with respect to the cost;

(a)  the cost of the prescription;

(b)  the amount insured; and

(c)  the uninsured surplus that may be required from the beneficiary, where applicable;

(2)  with respect to the contribution to the payment of the cost of pharmaceutical services and medications exigible from the beneficiary:

(a)  the deductible amount;

(b)  the 25% coinsurance amount;

(3)  the amount paid by the Board;

(4)  with respect to the state of the beneficiary’s maximum contribution for the reference period:

(a)  the amount of the contributions paid to date;

(b)  the remaining amount of the maximum contribution he must pay;

(5)  the reference number awarded by the Board.

O.C. 1519-96, s. 14.

15. (Obsolete).

O.C. 1519-96, s. 15.

16. (Omitted).

O.C. 1519-96, s. 16.

17. (Omitted).

O.C. 1519-96, s. 17.

REFERENCES

O.C. 1519-96, 1996 G.O. 2, 4941

O.C. 1532-96, 1996 G.O. 2, 4992

O.C. 364-97, 1997 G.O. 2, 1278

O.C. 431-97, 1997 G.O. 2, 1325

O.C. 582-97, 1997 G.O. 2, 1949

O.C. 776-97, 1997 G.O. 2, 2636

O.C. 973-97, 1997 G.O. 2, 4300

O.C. 1217-97, 1997 G.O. 2, 4996

O.C. 1709-97, 1997 G.O. 2, 6472

O.C. 391-98, 1998 G.O. 2, 1454

O.C. 834-98, 1998 G.O. 2, 2509

O.C. 1189-98, 1998 G.O. 2, 3949

O.C. 1473-98, 1998 G.O. 2, 4758

O.C. 9-99, 1999 G.O. 2, 84

O.C. 274-99, 1999 G.O. 2, 360

O.C. 781-99, 1999 G.O. 2, 1691

M.O. 99-09-29, 1999 G.O. 2, 3621

O.C. 1405-2000, 2000 G.O. 2, 5569

O.C. 620-2003, 2003 G.O. 2, 1841

S.Q. 2013, c. 28, s. 204