General Coverage Policies
PharmaCare’s 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 recognize for each drug. If the drug cost your pharmacy claims exceeds this maximum price, you pay the additional cost unless the Full Payment Policy (see below) applies.
Pharmacies charge a dispensing fee for each prescription they dispense. PharmaCare sets a maximum amount that it will reimburse (currently $10.00). If a pharmacy charges a dispensing fee higher than PharmaCare’s maximum fee amount, you will need to pay the difference in the cost unless the Full Payment Policy (see below) applies.
Under certain circumstances, a pharmacy cannot charge you more than the maximum drug price and maximum dispensing fee PharmaCare has set.
The policy applies when both the following apply:
- 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% coverage of the eligible costs of the 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 those charges to you.
Are there circumstances under which a pharmacy CAN charge me more than the maximums PharmaCare has set?
Yes, a pharmacy can charge above PharmaCare’s maximum amount if
- you are covered by Fair PharmaCare but have not yet met your Family Maximum. After reaching your deductible, PharmaCare covers 70% of your eligible costs. It does not cover 100% of your eligible costs until you meet your Family Maximum.
A pharmacy can also charge you above PharmaCare’s maximum amount for:
- 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—PharmaCare covers certain non-drug medical supplies such as prosthetics, orthotics, ostomy supplies, cystic fibrosis nutritional supplements, and diabetic supplies (insulin pumps, insulin pump supplies, needles and syringes, blood glucose test strips). These non-drug products are not subject to the Full Payment policy.
Can a pharmacy charge my private insurer?
If a pharmacy is able to determine at the time your prescription is dispensed that your private insurer will cover any costs in excess of the amount PharmaCare covers, 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 at a later date. The decision on coverage by your private insurer must be made at the time the medication is dispensed.
When you are covered by two or more PharmaCare plans
If you 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 under 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% 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% of his drug cost, not 100%. 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 may also be able to tell you if PharmaCare is covering 100% 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 maximum price for drugs in the LCA program set?
PharmaCare creates a separate 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 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%).
How does the LCA program benefit me?
The LCA program helps you in two ways:
- Saves taxpayer dollars and helps PharmaCare continue covering a broad range of drugs for you and all B.C. residents.
- It helps you pay less for your prescriptions. If you pay part of your drug costs out of your own pocket, the lower the overall cost, the lower your portion of the cost will be.
For more information, see Low Cost Alternative Program details.
Drug Shortage information
Find out about current provincial drug shortages, including any alternative(s) PharmaCare is covering.
- See the drug shortage list on the Drug Shortage Information page.
The Reference Drug Program (RDP) has been modernized. As a result, PharmaCare coverage of a number of drugs has changed, because evidence shows there are equally safe and effective drugs that cost less.
Read more about the Modernized RDP to find out which drugs are affected and what to do to maintain the maximum PharmaCare coverage of your drugs.
Sometimes, more than one type of drug can be used to treat the same illness or condition. The 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.
>> Learn more about Reference Drug Program
For short-term drug prescriptions—and for first-time prescriptions for longer-term "maintenance" drugs—PharmaCare covers only a maximum 30 days’ supply.
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 which 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 are available for 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 two-week supply of the drug.
This helps to eliminate the dangers of having excess medication on hand. It also avoids waste, especially if your treatment with a drug is discontinued while you still have a large supply. When this happens, the drug and any portion of the cost paid by you and by PharmaCare are wasted. Also, if you do not dispose of the medication correctly, it may harm the environment. (For more information on the safe disposal of unused medications, visit your local pharmacy.)
If you choose to get a refill of your medication and you still have more than a two-week supply, PharmaCare will not cover any portion of the cost.
Note: In some cases, after consultation with your pharmacist and perhaps with your physician, it may be determined that an early fill of your prescription is appropriate. In this case, PharmaCare would cover the eligible costs.
PharmaCare does not usually cover a prescription claim if you have more than 14 days’ supply left. 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 supply 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.
If you need more than the PharmaCare maximum days’ supply limit, only the maximum days’ supply will be eligible for coverage. 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 incidence of side effects. Dispensing a small quantity to start with prevents the medication being wasted 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.
Our Trial Prescription Program page provides a list of the drugs eligible for coverage of an additional dispensing fee.
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) now accepts faxed copies of patient-pay manual claims submissions via secure fax, submitted by either the patient of the provider on behalf of the patient.
For more information on the submission procedure, visit Manual Claims Submissions.