Pharmacare Tie-In
What
Does it
Really Mean?
Changes to the Extended Health Drug Coverage
for Groups Moving to a PharmaCare Tie-In
No Impact
If your drug is included on the BC Pharmacare
formulary you will not see a difference in the
coverage under your extended health plan.
To find out if a drug is on the Pharmacare formulary:
www.health.gov.bc.ca/pharmacare/benefitslookup
A search for "Tecta" brings up pantoprazole magnesium.
When you click on the drug name you get the summary below:
Special Authority Needed:
Some drugs require Special Authority from BC
PharmaCare before they will be covered under
PharmaCare and therefore by your Extended
Health Plan.
 There is no retroactive coverage. You must have a Special
Authority in place before filling a prescription for it to be
covered.
 You must provide a copy of the Special Authority to the
carrier (Pacific Blue Cross, Manulife, etc.) before they will
reimburse you for the drug.
The Ministry of Health Website:
http://www.health.gov.bc.ca/pharmacare/sa/criteria/genericbrandtable.html
This site contains a cross referenced list of drugs that require Special Authority and links
to the information specific to obtaining one for each drug:
Brand Name Drug: Tecta
Generic Drug:
pantoprazole magnesium
How to Access the BC Pharmacare
Special Authority Program:
STEP 1:
Make sure you are registered for Fair Pharmacare. If you are
not registered, you can register online or by telephone:
http://www.health.gov.bc.ca/pharmacare/
or
Call 604-683-7151 or 1-800-663-7100 (toll free)
Monday - Friday 8:00 a.m. to 8:00 p.m. and Saturday 8:00 a.m. - 4:00 p.m.
Step 2:
• Your doctor applies to Pharmacare for a
Special Authority on your behalf
• You should not be charged by your doctor for this service.
All forms must be completed by a licensed physician
and are available online at:
www.health.gov.bc.ca/pharmacare
Your doctor will fax the
completed request to the
number shown on the form.
Step 3:
• Pharmacare will notify your doctor of their
decision in writing.
• You should ask for a copy of the decision
document either from your doctor or directly
from Pharmacare.
• Ensure that you provide a copy of the approved
Special Authority to your extended health plan
carrier. You should only have to provide a copy of
the decision once per approved period.
Special Authority Process Overview
Physician, dentist or
hospital pharmacist
submits Special Authority
request to PharmaCare
By fax to 1-800-609-4884
PharmaCare assigns a priority level to the request
URGENT
PRIORITY
REGULAR
Decision within
one business day
Decision within
two business
days
Decision within
10 business days
Monday to Friday 8 a.m. to 8 p.m.
APPROVED
NOT APPROVED - more info required
DENIED
Decision communicated to applicant by fax/mail
Medication designated as a full benefit
subject to the usual PharmaCare plan
rules and deductible and copayment
requirements
Returned to physician, dentist or
hospital pharmacist
If your drug is not included on the BC Pharmacare
Formulary:
• You may opt to use the drug, but you will not be reimbursed
by your Extended Health Plan.
• Or you can ask your doctor to prescribe an alternative drug
that is covered under the PharmaCare formulary.
Some common drugs that are not covered:
•
•
•
•
•
Victoza (liraglutide)
Xolair (omalizumab)
Cymbalta (duloxetine)
Lyrica (pregabalin)
Tramacet
(tramadol/acetaminophen)
• Vyvance
•
•
•
•
•
Ezetrol (ezetimibe)
Singulair (montelukast)
Pristiq (desvenlafaxine)
Diane 35
Compounded products with
ingredients not covered by BC
PharmaCare
Low Cost Alternative (LCA) and Reference Based Drug
(RDP) Programs:
•
LCA categories consist of multi-source drugs sharing the same active ingredient (chemical
entity) recognizing the strengths and dosage forms that provide the best value.
•
Unlike the LCA Program, the RDP applies to different drugs (chemical entities) in the same
therapeutic category.
Links to Pharmacare's Low Cost Alternative (LCA) and Reference Drug Program (RDP) Data Files
can be found at:
http://www.health.gov.bc.ca/pharmacare/lca/lcabooklets.html
LCA Master Spreadsheet: Includes all new and existing generic drugs within the LCA program
with their current reimbursement limits.
RDA Master Spreadsheet: Includes all new and existing drugs within the RDP program with their
current reimbursement limits.
LCA /RDP Updates Workbook: Includes four spreadsheets that provide cumulative information
on all new generic drug listings, all new LCA categories, all changes and effective dates for
new LCA or RDP reimbursement limits, and any drug de-listings.
Low Cost Alternative Drug Program (LC):
bases PharmaCare coverage on the price of the lowest cost
brand among those drugs that have identical active ingredients.
If a drug is, or would be, part of an LCA category, the following applies:
•Full Benefits: These products are priced at or below the LCA price for the category.
They adjudicate at the lesser of the Pharmacare maximum price for the product or any
applicable Reference Drug Program (RDP) price.
•Partial Benefits: These are usually brand name products (exceptions are noted in the
LCA Data Files) within an LCA category priced above the LCA price. They adjudicate at
the lesser of the LCA price, the Pharmacare maximum price for the product, or any RDP
price applicable to the product. The patient is required to pay any portion of a drug's
cost that exceeds the LCA price (or RDP price, if applicable).
•Non-Benefits: Generic drugs that are priced above the maximum accepted list price
are not covered by Pharmacare. This includes products discontinued by the
manufacturer.
•If there is no designated LCA category for a benefit drug (on the formulary), it is
covered under existing Pharmacare policies.
Reference Based Drug Program (RDP):
applies to drugs that are not identical but are part of the same drug
category and are used to treat the same conditions.
• For most common medical conditions, drug manufacturers market a wide
variety of similar prescription drugs that often vary greatly in price but
achieve the same medical effect.
• Under the RDP, PharmaCare coverage is based on the cost of the reference
drug or drugs in a therapeutic category. This is the drug(s) considered to
be equally effective and the most cost effective in that category. The RDP
currently applies to five classes of drugs:
•
•
•
•
•
Histamine 2 receptor Blockers (H2 Blockers),
Non-Steroidal Anti-inflammatory drugs (NSAIDS),
Nitrates,
Angiotensin Converting Enzyme Inhibitors (ACE inhibitors), and
Dihydropyridine Calcium Channel Blockers (Dihydropyridine CCBs).
Reference Based Drug Program, continued
• Under this program, PharmaCare obtains independent, expert advice on
which prescription drug products within a group of similar medications are
equally safe and beneficial, and the most cost-effective.
• The cost of the preferred drug will then be the price of the "reference
drug" for the level of coverage that PharmaCare will establish for any
medication in that class used to treat that condition.
• Patients eligible for PharmaCare benefits will receive full coverage for the
preferred "reference" prescription drug, or may choose a more expensive
drug and pay only the difference in price.
• If a patient needs a more expensive drug for medical reasons, their doctor
may obtain Special Authorization from PharmaCare for full coverage of
that drug.
Fair Pharmacare: How does it fit in?
PharmaCare Annual Family Deductible: You are responsible for 100% of costs
until your eligible prescription and medical supply costs reach your
deductible. Once your family meets this amount, PharmaCare assists by
paying a percentage of further eligible expenses for the rest of the calendar
year.
Your Extended Health Plan (EHP): once you have met the annual EHP
deductible your plan will cover the cost that you must pay for these
prescriptions up to the limits contained in the plan. (e.g. many plans have an
80% co-insurance that either reimburses 80% of the cost or provides direct
pay drug benefits to 80% of the total cost).
The dispensing fees are also covered, but you need to be aware of whether
there is a cap to the amount covered by your EHP. (e.g. some plans cap these
fees at the PharmaCare maximum which is $10 per prescription for 2013)
When you reach your
Fair PharmaCare Annual Family Deductible:
• Fair PharmaCare will pay a portion of your prescription and medical
supply costs after you reach your annual family deductible. You and/or
your EHP will pay only the remaining portion of the cost. For example, if
the PharmaCare portion is 70%, you (and/or your EHP) would need to pay
the remaining 30% of your eligible prescription costs until you reach your
Annual Family Maximum.
• Your Extended Health Plan (EHP): Will cover the remaining 30% of eligible
prescription costs, reimbursed at the level contained in your EHP.
• Example: A family with a combined income of $40,000.00
• will have an annual family deductible of $1,200.00.
• Once they have paid for (or had covered by their EHP) $1200 of
prescriptions and medical supplies, PharmaCare will cover 70% of future
costs (with a maximum dispensing fee of $10) and the other 30% will be
paid through the EHP at the levels contained in the plan.
When you reach your
Fair PharmaCare Annual Family Maximum:
Annual Family Maximum:
• Our example family will have an annual family maximum of $1,600.00.
• Once they have met their annual family maximum of for the year,
PharmaCare will cover 100% of their eligible prescription and medical
supply costs, again with a maximum $10 dispensing fee per
prescription, for the rest of the calendar year.
• If PharmaCare covers 100% of the cost then your EHP does not pay any
part of the cost.
PDF file showing Annual Deductibles by Net Income can be
found at:
http://www.health.gov.bc.ca/pharmacare/plani/calculator/pdf/income_bands_fair_pcare_regular.pdf
Family Net Income Range
$0.00
$1,875.01
$3,125.01
$4,375.01
$6,250.01
$8,750.01
$11,250.01
$13,750.01
$15,000.01
$16,250.01
$18,750.01
$21,250.01
$23,750.01
$26,250.01
$28,750.01
$30,000.01
$31,667.01
$35,000.01
$38,333.01
$41,667.01
$45,000.01
$48,333.01
$51,667.01
$55,000.01
Family Deductible
$1,875.00
$3,125.00
$4,375.00
$6,250.00
$8,750.00
$11,250.00
$13,750.00
$15,000.00
$16,250.00
$18,750.00
$21,250.00
$23,750.00
$26,250.00
$28,750.00
$30,000.00
$31,667.00
$35,000.00
$38,333.00
$41,667.00
$45,000.00
$48,333.00
$51,667.00
$55,000.00
$58,333.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$0.00
$300.00
$350.00
$400.00
$450.00
$500.00
$550.00
$600.00
$900.00
$1,000.00
$1,100.00
$1,200.00
$1,300.00
$1,400.00
$1,500.00
$1,600.00
$1,700.00
Portion PharmaCare pays
after deductible is met
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
Family Maximum
PharmaCare covers 100%
of costs for the rest of the
year after the maximum is
met
$25.00
$50.00
$75.00
$100.00
$150.00
$200.00
$250.00
$300.00
$450.00
$525.00
$600.00
$675.00
$750.00
$825.00
$900.00
$1,200.00
$1,350.00
$1,475.00
$1,600.00
$1,750.00
$1,875.00
$2,000.00
$2,150.00
$2,275.00
If you have not filed income tax returns or are not registered for Fair
PharmaCare your annual family deductible is $10,000.00
only after you have met this deductible will PharmaCare will pay 100% of the eligible
costs.
Family Net Income Range
$58,333.01
$61,667.01
$65,000.01
$70,833.01
$79,167.01
$87,500.01
$95,833.01
$108,333.01
$125,000.01
$141,667.01
$158,333.01
$183,333.01
$216,667.01
$250,000.01
$283,333.01
$316,667.01
$61,667.00
$65,000.00
$70,833.00
$79,167.00
$87,500.00
$95,833.00
$108,333.00
$125,000.00
$141,667.00
$158,333.00
$183,333.00
$216,667.00
$250,000.00
$283,333.00
$316,667.00
$999,999,999.00
Family Deductible
Portion PharmaCare pays
after dedcuctible is met
$1,800.00
$1,900.00
$2,000.00
$2,250.00
$2,500.00
$2,750.00
$3,000.00
$3,500.00
$4,000.00
$4,500.00
$5,000.00
$6,000.00
$7,000.00
$8,000.00
$9,000.00
$10,000.00
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
70%
100%
Deductible for a family registered for Fair PharmaCare
whose income cannot be verified
$10,000.00
100%
Deductible for a person actively enrolled in the Medical
Services Plan but not registered for Fair PharmaCare
$10,000.00
100%
Family Maximum
PharmaCare covers 100%
of costs for the rest of the
year after the maximum is
met
$2,400.00
$2,550.00
$2,675.00
$3,000.00
$3,350.00
$3,675.00
$4,000.00
$4,675.00
$5,350.00
$6,000.00
$6,675.00
$8,000.00
$9,350.00
$10,000.00
$10,000.00
$10,000.00
Other Resources:
Pacific Blue Cross:
http://www.pac.bluecross.ca/Corp/howbenefitswork/getthemost/
Has information sheets posted on:
•
•
•
•
•
•
•
•
•
•
•
Coordination of Benefits
PharmaCare and your Blue Cross Drug Plan
Ways to Save Costs
Prevent Fraud
Employee Family Assistance Program
Second Opinion
Disease Management Support Programs
Health and Wellness
Heath Protection Plus
Pay Direct Drugs
Blue Advantage Savings Program
•
•
•
•
•
•
•
•
•
Direct Deposit and eStatements How-To Guide
Online Self Service
10 things to ask your pharmacist
10 things to ask your doctor
Brand name drugs vs Generics
Understanding prescription drug prices
Low-cost alternative drug pricing
Pharmacy Compass
Link to "Frequently Asked Questions" that
provides brief information on multiple topics
Pacific Blue Cross:
Pharmacy Compass
http://www.pharmacycompass.ca/
This site provides a cost comparison for pharmacies in your area and is accessible to
the general public.
Pharmacy Compass, continued
A map showing the locations of the identified pharmacies is also provided below the
summary.
To Contact BC Pharmacare:
Vancouver: 604-683-7151
From the rest of BC: toll free: 1-800-663-7100
Monday to Friday, 8:00 a.m. to 8:00 p.m.
Saturday 8:00 a.m. to 4:00 p.m.
(except Statutory holidays)
You can register for Fair PharmaCare 24 hours a day, 7 days a week if
you meet the eligibility requirements for online registration.
Fair Pharmacare:
For information related to the BC Fair PharmaCare Program go to:
http://www.health.gov.bc.ca/pharmacare/fpcreg.html
An online calculator found at:
http://www.health.gov.bc.ca/pharmacare/plani/calculator/calculator.html
can be used to estimate of your Fair PharmaCare plan deductibles by entering
the information requested.