Orphan Drug Coverage

Definition

Orphan Drug Coverage (Canadian insurance): An optional benefit offered under extended or supplementary health plans—usually sponsored by an employer, union, or purchased privately—that reimburses the extremely high cost of certain prescription medicines used to diagnose, treat, or prevent a very rare disease (defined in Canadian regulations as a condition affecting fewer than 5 in 10,000 people). Because Health Canada has designated these medications as “orphan drugs,” their limited market size would otherwise make them inaccessible. When a plan includes this coverage, the insurer will pay part or all of the drug cost after any applicable deductible, coinsurance, special prior-authorization criteria (for example, proof from a specialist that other treatments have failed), and coordination with federal or provincial drug access programs.
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Coverage Type

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