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Family Pharmacare Program Regulations

made under subsections 6(2), 7(1) and 31(1) of the

Fair Drug Pricing Act

S.N.S. 2011, c. 7

O.I.C. 2011-234 (June 30, 2011, effective July 1, 2011), N.S. Reg. 225/2011


Citation

1     These regulations may be cited as the Family Pharmacare Program Regulations.


Definitions

2     In these regulations,

 

“Act” means the Fair Drug Pricing Act;

 

“adjusted annual family income” means a family unit’s annual income as adjusted in accordance with Section 7;

 

“adult” means a resident who is 18 years old or older;

 

“annual family deductible” means the deductible that a family unit must pay for coverage under the Program under Section 8;

 

“benefit period” means April 1 to March 31 of the following year;

 

“common law partner” of an individual means another individual who has cohabited with the individual in a conjugal relationship for a period of at least 1 year;

 

“CRA” means the Canada Revenue Agency;

 

“family unit” means a resident or group of residents who meet the criteria for 1 of the categories of family units set out in Section 3;

 

“health card” means identification with a person’s health card number and issued by the Minister;

 

“health card number” means a unique identification number assigned by the Minister to individuals insured under the Health Services and Insurance Act;

 

“maximum annual family unit copayment” means the maximum amount a family unit must pay annually as copayments under Section 11;

 

“Program” means the Family Pharmacare Program, a program under the Plan that provides pharmacare coverage to uninsured or underinsured families

 

“spouse” means, with respect to any individual, an individual who is cohabiting with that individual in a conjugal relationship as married spouse, registered domestic partner or common-law partner.


Categories of family units

3     (1)    The following are the categories of family units:

 

                (a)    a single adult;

                (b)    an adult and a spouse;

                (c)    an adult and all their dependants;

                (d)    an adult, a spouse, and all their dependants.

 

       (2)    A person must meet all of the following criteria to be considered a dependant under the Act:

 

                (a)    the person is a child or legal ward of an adult;

                (b)    the person is younger than 18 years old age as of

                         (i)     April 1, or

                         (ii)    the first day of the month in which enrolment in the Program is applied

for;

                (c)    the person is supported by an adult;

                (d)    the person does not have a spouse.


Program coverage

4     (1)    Coverage under the Program is available to all residents, other than residents who are excluded under subsection (2).

 

       (2)    A member of a family unit is not eligible for coverage under the Program if any of the following apply to the member:

 

                (a)    they are enrolled in the Seniors’ Pharmacare Program under the Seniors’ Pharmacare Program Regulations made under the Act;

 

                (b)    they are enrolled in any of the following programs run by the Department of Health and Wellness:

 

                         (i)     the Nova Scotia Diabetes Assistance Program,

 

                         (ii)    the Under 65 Long Term Care Pharmacare Program;

 

          (d)[(c)]   they are receiving drug coverage under the Employment Support and Income Assistance Act;

 

          (e)[(d)]   they are receiving drug coverage under the Low Income Pharmacare Program for Children under the Act.

 

       (3)    For greater certainty, a member of a family unit is not disqualified from coverage under the Program because they are receiving benefits under any of the following programs run by the Department of Health and Wellness:

 

                (a)    the Exception Drug Fund;

 

                (b)    the Drug Assistance for Cancer Patients Program;

 

                (c)    any special funding provided for specific diseases.

 

       (4)    Coverage under the Program is insurance of last resort and no amount may be paid under these regulations for benefits supplied to any beneficiary if

 

                (a)    coverage in respect of the benefits has been paid under any contract or plan of insurance that applies to the beneficiary; or

 

                (b)    coverage in respect of the benefits would be payable if claimed under any contract or plan of insurance that applies to the beneficiary.


Enrolment in Program

5     (1)    A family unit may apply for coverage under the Program at any time.

 

       (2)    To re-enroll in the Program, a family unit must apply for re-enrolment on or before April 1 of each year.

 

       (3)    An individual may only be enrolled in 1 family unit.


Proof of eligibility for Program

6     (1)    To establish eligibility for the Program, each member of a family unit must provide proof of all of the following:

 

                (a)    a valid health card;

 

                (b)    except as provided in subsection (2), a valid social insurance number;

 

                (c)    if the member was a resident within the 2 years immediately before the application for enrolment, the member’s latest Notice of Assessment from the CRA;

 

                (d)    complete family unit information as required by the Minister.

 

       (2)    Proof of a Social Insurance Number is not mandatory for a dependant, and 1 adult Social Insurance Number for a family unit is adequate if a spouse does not possess a Social Insurance Number.

 

       (3)    Each member of a family unit must agree that the Department of Health and Wellness may verify any income information provided under clause (1)(c) through the CRA.


Adjusted annual family income calculation

7     (1)    For the purpose of calculating a family unit’s deductible and copayments payable under the Program, the family unit’s annual family income must be adjusted in accordance with subsection (2).

 

       (2)    A family unit’s adjusted annual family income is determined by using the gross family income reported on line 150 of the latest Notice of Assessment from the CRA minus $3000 for 1 spouse and $3000 for each dependant.


Annual family deductible

8     (1)    A family unit enrolled in the Program must pay an annual family deductible based on the family unit’s adjusted annual family income and calculated in accordance with the following table:


Adjusted Annual Family Income Range

Deductible

Maximum Annual Family Deductible as a Percentage of Adjusted Annual Family Income

Amount of

Annual Family Deductible

Less than $10 000

1.0%

$0 to $100

$10 000 to <15 000

1.0%

$100 to $150

$15 000 to <$17 000

1.5%

$225 to $255

$17 000 to <$20 000

2.0%

$340 to $400

$20 000 to <$25 000

2.5%

$500 to $625

$25 000 to <$30 000

3.0%

$750 to $900

$30 000 to <$35 000

3.5%

$1050 to $1225

$35 000 to <$40 000

4.0%

$1400 to $1600

$40 000 to <$45 000

4.5%

$1800 to $2025

$45 000 to <$50 000

5.0%

$2250 to $2500

$50 000 to <$52 000

5.5%

$2750 to $2860

$52 000 to <$54 000

6.0%

$3120 to $3240

$54 000 to <$55 000

6.5%

$3510 to $3575

$55 000 to <$57 000

7.0%

$3850 to $3990

$57 000 to <$58 000

7.5%

$4275 to $4350

$58 000 to <$60 000

8.0%

$4640 to $4800

$60 000 to <$61 000

8.5%

$5100 to $5185

$61 000 to <$63 000

9.0%

$5490 to $5670

$63 000 to <$65 000

9.5%

$5985 to $6175

$65 000 to <$67 000

10.0%

$6500 to $6700

$67 000 to <$68 000

10.5%

$7035 to $7140

$68 000 to <$70 000

11.0%

$7480 to $7700

$70 000 to <$71 000

11.5%

$8050 to $8165

$71 000 to <$73 000

12.0%

$8520 to $8760

$73 000 to <$75 000

12.5%

$9125 to $9375

$75 000 to <$77 000

13.0%

$9750 to $10 010

$77 000 to <$78 000

13.5%

$10 395 to $10 530

$78 000 to <$80 000

14.0%

$10 920 to $11 200

$80 000 to <$81 000

14.5%

$11 600 to $11 745

$81 000 to <$83 000

15.0%

$12 150 to $12 450

$83 000 to <$85 000

15.5%

$12 865 to $13 175

$85 000 to <$87 000

16.0%

$13 600 to $13 920

$87 000 to <$88 000

16.5%

$14 355 to $14 520

$88 000 to <$90 000

17.0%

$14 960 to $15 300

$90 000 to <$91 000

17.5%

$15 750 to $15 925

$91 000 to <$93 000

18.0%

$16 380 to $16 740

$93 000 to <$95 000

18.5%

$17 205 to $17 575

$95 000 to <$97 000

19.0%

$18 050 to $18 430

$97 000 to <$98 000

19.5%

$18 915 to $19 110

$98 000 and over

20.0%

$19 600 and over

 

       (2)    A family unit enrolled in the Program must pay any remaining cost after the copayment calculated under Section 9 is paid until their annual family deductible is paid in full.

 

       (3)    Payments made under subsection (2) must be

 

                (a)    applied towards payment of the annual family deductible until the annual family deductible is paid in full; and

 

                (b)    paid directly by the beneficiary to the participating pharmacy at the time of purchase.


Family unit copayment

9     (1)    Each beneficiary must pay 20% of the cost of a benefit directly to the provider at the time of purchase.

 

       (2)    The maximum annual family unit copayment is based on the family unit’s adjusted annual family income and calculated in accordance with the following table:


Adjusted Annual Family Income Range

Maximum Annual Family Unit Copayment as a Percentage of Adjusted Annual Family Income

Maximum Annual Family Unit Copayment

Less than $10 000

4.0%

0 to $400

$10 000 to <$20 000

5.0%

$500 to $1000

$20 000 to <$30 000

6.0%

$1200 to $1800

$30 000 to <$40 000

8.0%

$2400 to $3200

$40 000 to <$50 000

9.5%

$3800 to $4750

$50 000 to <$60 000

11.0%

$5500 to $6600

$60 000 to <$70 000

12.0%

$7200 to $8400

$70 000 to <$80 000

13.0%

$9100 to $10 400

$80 000 to <$90 000

14.0%

$11 200 to $12 600

$90 000 and over

15.0%

$13 500 and over

Adjustments during benefit period

10   (1)    The annual family deductible and maximum annual family unit copayment must not be recalculated or refunded during a benefit period because of changes in family unit size or income.

 

       (2)    The annual family deductible and maximum annual family unit copayment must not be pro-rated for a family unit that enrols in the Program part way through the benefit period.

 

       (3)    If a family unit leaves the Program and re-enrols in the Program during a single benefit period, any amounts they paid towards their annual family deductible or their maximum annual family unit copayment must be counted towards their annual family deductible and maximum annual family unit copayment respectively when they re-enrol.


Purchases made before date of coverage

11   A beneficiary must not be reimbursed for benefits they purchased before the date their coverage under the Program begins.