General Coverage Policies

The following general coverage policies apply to all PharmaCare plans. Understanding these policies can help you manage your prescription and medical supply costs.

PharmaCare sets a maximum price it will pay for each drug. If the amount submitted by your pharmacy exceeds the maximum price, you pay the additional cost, unless the Full Payment Policy applies.

Pharmacies charge a dispensing fee for each prescription. PharmaCare sets a maximum amount that it will reimburse (currently $10.00). If a pharmacy charges a dispensing fee higher than PharmaCare’s maximum amount, you pay the additional cost, unless the Full Payment Policy applies.

In certain circumstances, a pharmacy cannot charge you more than the PharmaCare maximum drug price and dispensing fee.

The Full Payment Policy applies when both of the following conditions are met:

  • You are receiving full (100%) PharmaCare coverage*, and
  • The drug/product is eligible for full PharmaCare reimbursement

* Individuals covered by any PharmaCare plan receive 100 percent coverage of the eligible costs of items covered by their plan—except individuals covered by the Fair PharmaCare plan who have not yet met their family maximum. Please see the following question for more information.

If a pharmacy mistakenly charges you when the Full Payment Policy applies, they must refund you.

When CAN a pharmacy charge me more than the maximums PharmaCare has set?

A pharmacy can charge above PharmaCare’s maximum amount if

  • You are covered by the Fair PharmaCare plan but have not yet met your family maximum. After reaching your deductible, PharmaCare covers 70 percent of your eligible costs. It does not cover 100 percent of your eligible costs until you meet your family maximum

A pharmacy can also charge you above PharmaCare’s maximum amount for

  • Insulin
  • A drug or product that is not a PharmaCare benefit
  • A drug or product that is only a partial PharmaCare benefit under the Low Cost Alternative (LCA) program or Reference Drug Program (RDP)
  • A product that is not a drug, e.g. ostomy supplies, cystic fibrosis nutritional supplements, diabetes supplies, and medical devices such as prostheses and orthoses. These non-drug products are not subject to the Full Payment Policy

Can a pharmacy charge my private insurer?

If a pharmacy can determine at the time your prescription is dispensed that your private insurer covers any costs in excess of the amount covered by PharmaCare, the pharmacy can charge your private insurer.

A pharmacy cannot charge you on the understanding that your private insurer may pay all or some of the cost later. The decision on coverage by your private insurer must be made at the time the medication is dispensed.

What if I am covered by more than one PharmaCare plan?

If you are covered under more than one PharmaCare plan, some of your drugs may be subject to the Full Payment Policy while others are not.

For example, Robert is covered under Fair PharmaCare and the Psychiatric Medication Plan (Plan G). Robert has two prescriptions to fill. One is for a psychiatric drug covered under Plan G. The other is for a skin ointment covered under Fair PharmaCare.

Since Plan G provides 100 percent coverage of the eligible costs of the psychiatric drug, the prescription is subject to the Full Payment Policy and Robert will not be charged any additional amount for the drug.

The prescription for the ointment will not be subject to the Full Payment Policy. This is because, although Robert has met his Fair PharmaCare deductible, he has not reached his family maximum, so PharmaCare is covering only 70 percent of his drug cost, not 100 percent. Robert will have to pay the amount PharmaCare does not cover (30%) and any amount the pharmacy charges in addition to that.

How do I find out if I have met my family maximum?

Call Health Insurance BC. Your pharmacist is also able to tell you if PharmaCare is covering 100 percent of the eligible costs of your prescriptions.

PharmaCare’s Low Cost Alternative (LCA) program helps control the cost of prescription drugs. When the same drug is made and sold by more than one manufacturer, PharmaCare covers the less costly version—the low cost alternative.

How is the LCA maximum price set?

PharmaCare creates a category for each type of drug based on its active ingredient, its strength and its formulation (tablet, capsule, etc.). For example, there is one category for acetaminophen 250 mg tablets and another category for acetaminophen 500 mg tablets.

PharmaCare sets a maximum price it will cover for each category. The coverage amount is based on a percentage of the price of the brand name drug. If a manufacturer wants its generic drug included on the list of LCA drugs that PharmaCare covers, it has to agree to sell the generic drug to pharmacies at or below the maximum price.

PharmaCare covers the drug up to the maximum list price plus a fixed markup for pharmacies (usually 8 percent).

How does the LCA program benefit me?

The LCA program

  • Saves taxpayer dollars, which helps PharmaCare continue to cover a broad range of drugs for all B.C. residents
  • Helps you pay less for your prescriptions. If you pay part of your drug costs out of your own pocket, then the lower the overall cost, the lower your portion of the cost will be

For more information, see Low Cost Alternative Program.

Sometimes, more than one type of drug can be used to treat the same illness or condition. The Reference Drug Program (RDP) groups together drugs that treat the same illness or medical condition (such as high blood pressure or high cholesterol), then fully covers one or more of the less costly drugs. Other drugs within the group are eligible for partial coverage.

For more information, see Reference Drug Program.

PharmaCare covers a maximum 30-day supply for:

  • Short-term drug prescriptions
  • First-time maintenance drug prescriptions

When you refill a prescription for a drug intended for longer term use, PharmaCare covers a 100-day supply.

Short-term medications include antibiotics, sedatives, sleeping pills and barbiturates. Some of these medications are addictive or become ineffective if used over a long period of time.

Maintenance drugs include those used for chronic conditions such as diabetes and Parkinson's disease.

Exemptions to this policy can apply to residents of rural or remote areas without a pharmacy nearby.

PharmaCare may not cover a prescription if you fill it when you still have more than a 14-day supply of the drug.

This helps eliminate the dangers of having excess medication on hand. It also avoids waste, in case your treatment is discontinued while you have a supply. When this happens, the drug and any cost paid by you and by PharmaCare is wasted. Also, medication incorrectly disposed of may harm the environment.

If you choose to get a refill of your medication while you have more than a 14-day supply, PharmaCare will not cover any portion of the cost.

PharmaCare does not usually cover a prescription if you have more than a 14-day supply left from the previous fill. However, PharmaCare allows you to fill a prescription earlier if you need a supply for travel outside B.C.

Once every six months (180 days), if you are travelling out of province, you can top up your existing prescription(s) to the maximum days’ supply recognized by PharmaCare as described below:

  • PharmaCare coverage of the first fill of an eligible drug intended for long-term use—and the first fill/refill of a prescription for an eligible drug intended for short-term use—is limited to a 30-day supply
  • PharmaCare coverage for each refill of a prescription for an eligible drug intended for long‑term use is limited to a 100-day supply

For your travel supply to be eligible for PharmaCare coverage, you must complete and sign a Travel Declaration form (supplied by your pharmacy) on the date your prescription is filled.

Only the maximum days’ supply will be eligible for coverage. If you need more than the PharmaCare maximum days’ supply, you will be responsible for any remaining cost.

If you are covered under the Fair PharmaCare plan, only the portion of your prescription eligible for PharmaCare coverage will count towards your deductible and/or family maximum.

The Trial Prescription Program encourages the dispensing of small quantities (10 to 14 days’ supply) of specific expensive medications that have a high rate of side effects. Dispensing a small quantity to start prevents medication waste if you do not tolerate the drug well.

PharmaCare covers the initial dispensing fee for the trial quantity—you pay only the portion of the dispensing fee and drug costs not covered under your PharmaCare plan rules. If you fill the remainder of the prescription, you pay only your portion of the remaining drug cost and the dispensing fee, according to your PharmaCare plan rules.

The Trial Prescription Program page provides a list of drugs eligible for the additional dispensing fee coverage.

Occasionally, PharmaCare providers require patients to pay for the cost of eligible benefits upfront. In these instances, the patient may request direct reimbursement from PharmaCare. Health Insurance BC (HIBC) accepts faxed copies of patient-pay manual claims submissions via secure fax, submitted by the patient or the provider on behalf of the patient. 

For more information, visit Manual Claims Submissions.

 

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