Catastrophic Drug Program

If the cost of your prescription medication is making it hard for you to pay other essential life expenses, you may qualify for coverage of certain medications through the Catastrophic Drug Program.

Am I eligible?

You, your spouse, and dependents are eligible for this program if you meet ALL the following criteria:

• are a PEI resident as defined by the Drug Cost Assistance Act.
• have a valid PEI Health Card; and
• you have filed your Prince Edward Island tax returns and agree to household income verification through Canada Revenue Agency.

When am I eligible for coverage?

Once approved, your eligibility will start from the date noted in your approval letter, and will continue until June 30. To avoid interruption in coverage, you must re-apply each year.

How do I apply? 

Submit a completed Catastrophic Drug Program Application form  [PDF | 305 KB] to PEI Pharmacare. 

What if I’m already in a government drug program? 

Islanders who currently have coverage through other public drug programs such as the Seniors’ or Diabetes programs also qualify for benefits through the Catastrophic Drug Program, should they spend more than their household cap on eligible prescription costs. 

How is cost assistance calculated? 

Your annual out-of-pocket costs for eligible prescription medications will be capped at an amount not to exceed a set percentage of your household income. Eligible prescription medication costs for the remainder of the year from July 1 to June 30 will be paid through the Catastrophic Drug Program. 

Out-of-pocket costs are considered the eligible costs paid by the household.

Note: prescription costs paid for by another person, patient support program or third party insurer are not considered "out-of-pocket". It is the patient’s responsibility to notify PEI Pharmacare if another person, patient support program or paper based third party insurer is paying any portion of the copayment; failure to do so may result in the recovery of any benefits paid.

How do we define “Household Income”?

For each household member, use Line 150 (Total Income) from the preceding year’s tax return, and deduct any amounts reported on lines # 210 (Split–Pension Amount), # 214 (Child Care Expenses), # 220 (Support Payments Made). This amount represents each individual’s income for the purpose of drug program coverage. Add together the individual amounts for each household member identified above to determine total household income.

How do we calculate “Household Cap”?

Take the household income you just calculated, determine which income range you fall under, multiply the total household income by the appropriate percentage.

If your total annual household income is:

• Up to $20,000 you will pay 3% of your annual income on prescription medication costs before assistance;
• Greater than $20,000 to $29,999 you will pay 3.25% of your annual income on prescription medication costs before assistance;
• Greater than $30,000 to $39,999 you will pay 3.5% of your annual income on prescription medication costs before assistance;
• Greater than $40,000 to $49,999 you will pay 3.75% of your annual income on prescription medication costs before assistance;
• Greater than $50,000 to $59,999 you will pay 4% of your annual income on prescription medication costs before assistance;
• Greater than $60,000 to $69,999 you will pay 4.25% of your annual income on prescription medication costs before assistance;
• Greater than $70,000 to $79,999 you will pay 4.5% of your annual income on prescription medication costs before assistance;
• Greater than $80,000 to $89,999 you will pay 4.75% of your annual income on prescription medication costs before assistance;
• Greater than $90,000 to $99,999 you will pay 5% of your annual income on prescription medication costs before assistance;
• Greater than $100,000 to $109,999 you will pay 5.25% of your annual income on prescription medication costs before assistance;
• Greater than $110,000 to $119,999 you will pay 5.5% of your annual income on prescription medication costs before assistance;
• Greater than $120,000 to $129,999 you will pay 5.75% of your annual income on prescription medication costs before assistance;
• Greater than $130,000 to $139,999 you will pay 6% of your annual income on prescription medication costs before assistance;
• Greater than $140,000 to $149,999 you will pay 6.25% of your annual income on prescription medication costs before assistance;
• Greater than $150,000 you will pay 6.5% of your annual income on prescription medication costs before assistance.

Example:
Annual household income: $55,000 x 4% = $2,200 cap

Once you have spent $2,200 for eligible prescription medications, you will be covered by the Catastrophic Drug Program for additional approved medication costs for the remainder of the year (July 1 – June 30).

If you apply past the program start date of July 1, your cap will be pro-rated to reflect the percentage of time remaining until June 30.

What is considered a household?

A household may consist of an:

• a single adult
• an adult and spouse (refer to definition below)
• an adult and all dependent children (refer to definition below)
• an adult, spouse, and all dependent children

Note: Include all family members on the Catastrophic Drug Program application form, even if some family members have drug coverage through other programs. All family members are included in the calculation of household cap.

How do we define “Spouse”?

A spouse is:

• is married to the other person
• is common law with the other person, or
• is living with the other person in a conjugal relationship

How do we define “Dependent”?

A dependent is:

• a child or a legal ward of you or your spouse
• under the age of 18 years, or under the age of 25 and attending a post-secondary institution on a full-time basis - confirmation of enrolment from the post-secondary institution is required.
• not married and not living in a marriage-like relationship

A dependent can only be registered with one family at any given time.

What if I am single, 18 years of age or over and still living with my family?

If you are 18 years of age or over, and NOT a full-time student, you must complete your own registration form. If you live with your parents and do not have a spouse or dependents, you are considered a family of one for our purposes. Do not include your parents’ names or their incomes on your registration form.

How much of the medication cost will be covered?

All costs of eligible medications are covered by the program after the household cap amount has been reached. Eligible medications are listed on the PEI Pharmacare Formulary.

Medication available over-the-counter, or funded through another public drug program, are not covered through this program.

What if I have private insurance?

You or your pharmacy must submit all claims to your private insurer first. The remaining out-of-pocket eligible expense can then be submitted to PEI Pharmacare for assessment.

The portion you pay out-of-pocket at your pharmacy for eligible medications will still count toward your household accumulator. The annual premium you pay your insurance company may be used to reduce your household income by up to $2,500 when calculating the household cap amount.

What if my medication is not listed in the PEI Pharmacare Formulary?

Some medications in the PEI Pharmacare Formulary are approved on a special authorization basis only. If your physician prescribes a drug in this category, he or she can submit a Standard Special Authorization Request form [PDF | 34 KB] to have a medication considered for coverage.

If your medication is not included in the PEI Pharmacare Formulary, it will not be eligible for coverage.

Where can I get my medication?

You can have your prescription filled at any community retail pharmacy located in Prince Edward Island.

Will my medications be eligible for coverage if they are filled at an out of province pharmacy?

Claims are eligible for manual submission only if the  medication or any formulation of the medication cannot be dispensed through a PEI pharmacy.

How can I contact PEI Pharmacare?

PEI Pharmacare
16 Fitzroy Street
Sullivan Building
Charlottetown, PE C1A 7N8

Telephone: (902) 368-4947
Toll free: 1-877-577-3737