3.4 Patients - Other Payers

[July 2019: Updated for change of Opioid Agonist Treatment Provider sub-class]

General Policy Description

Patients may be covered by extended health insurance. Private insurers are companies, such as Pacific Blue Cross and Great West Life, that provide private, extended health insurance benefits that supplement the health care benefits of provincial programs (such as MSP and PharmaCare).

PharmaCare is a provincial government reimbursement program and is not affiliated with any extended health insurance provider.

Community pharmacies have online access to some third-party insurers, such as Pacific Blue Cross and Assure. PharmaCare is not responsible for resolving any connection or adjudication problems that pharmacies may have with a third-party insurer.
Patients may also have coverage through:

• A federal or other government insurer such as Veterans Affairs Canada, the Interim Federal Health Program, or ICBC
• An award for damages or settlement

On this page:

Policy details

PharmaCare does not provide claim adjudication results to other third-party payers.

Some third-party insurers (who provide private, extended health benefits) follow PharmaCare Special Authority (SA) requirements. Some third-party insurers provide coverage only if:

• PharmaCare has granted SA for the prescription 
• PharmaCare SA was granted before the prescription was filled (i.e., they do not provide retroactive coverage) 

All enquiries regarding retroactive coverage by a third-party insurer should be directed to the specific insurers, not PharmaCare.

WorkSafeBC/Insurance Corporation of BC (ICBC)

Eligible medication costs for WorkSafeBC clients must be claimed from WorkSafeBC, not PharmaCare.

Eligible medication costs for ICBC clients must be claimed from ICBC, not PharmaCare.

Federal coverage

PharmaCare is not the first payer for BC residents covered by the following federal plans:

• Veterans Affairs Canada (VAC)
• Canadian Forces
• Non-Insured Health Benefits (NIHB) Program

Note: Many First Nations clients are covered by PharmaCare Plan W. They may also be eligible for federal coverage from Veterans Affairs Canada or the Canadian Forces.

First Nations individuals who are not eligible for Plan W continue to receive coverage through the NIHB. 

The Patient Coordination of Benefits Table, a “behind-the-scenes” table on PharmaNet, is loaded with PHNs for all B.C. residents covered by the above federal government agencies/programs.

PharmaCare does not cover drug costs for B.C. residents when they are full benefits under a federal plan. Only costs not reimbursed through federal coverage may be eligible for PharmaCare coverage.

Exceptions may be made to this policy under the Smoking Cessation Program.

Coverage for federal and provincial inmates and offenders

Federal offenders

PharmaCare does not cover persons in custody in a federal institution as their drug costs are covered as part of the cost of their incarceration.

PharmaCare does cover federal offenders who have been released on day parole and approved to reside in a community-based residential facility.

Provincial offenders

PharmaCare does not cover persons in custody in a provincial institution as their drug costs are covered as part of the cost of their incarceration.

PharmaCare does not cover provincial offenders who have been released on day parole but who must return to a correctional centre each night.

PharmaCare does cover provincial offenders who have been approved to reside in a community based residential facility.

Note: As of October 1, 2017, when an individual is released from a provincial corrections facility, the Provincial Health Services Authority is responsible for providing a short supply of medication to that individual, subject to some limitations.

>> For more information, see the Health Care Services Manual of the Adult Custody Division, Section 7.16–Medications Upon Release (PDF, 690KB) from the Adult Custody Division, Corrections Branch, Ministry of Public Safety and Solicitor General. 

Awards for damages or settlements

If an individual has been, or will be, compensated for an injury, illness or other condition through an award for damages or settlement, PharmaCare does not cover the cost of any benefit used to treat that injury, illness, or other condition.

This policy does not apply to claims for clinical services or under the BC Smoking Cessation Program.

Ineligible costs

PharmaCare does not reimburse the cost of an eligible benefit if:

• The need for the benefit arose from an injury, illness or other condition alleged to have been caused by an act or omission of another person, and as a result of the allegations:
  • a court has awarded damages to the beneficiary,
  • the beneficiary is entitled to compensation under a settlement agreement, or
  • the beneficiary is entitled to compensation under a plan of private insurance or another legal instrument

Specifically, unless all damages or compensation payable have been fully exhausted, PharmaCare does not cover benefits when:

• A court has awarded damages to an individual for future care costs for drugs, devices, substances or related services; or 
• A court has awarded damages to an individual for future care costs and the award does not distinguish between future care costs for drugs, devices, substances or related services and future care costs payable for other future care; or
• A court has awarded damages to an individual but the award does not specify the types of damages; or
• An individual is entitled to compensation under a settlement agreement for future care costs for drugs, devices, substances or related services; or
• An individual is entitled to compensation under a settlement agreement for future care costs that does not distinguish between future care costs for drugs, devices, substances or related services and future care costs payable for other future care; or
• An individual is entitled to compensation under a settlement agreement that does not specify the types of damages.

Eligible costs

PharmaCare covers benefits required by an injury, illness or other condition when:

• A court has determined that no damages should be awarded to the individual.
• The individual is not entitled to any compensation under a settlement agreement.
• The individual has a potential claim for damages for the injury or illness, but liability has not yet been determined and no court has made an award for damages, nor has any settlement agreement for compensation been made.
• All damages or compensation payable for future care costs for drugs, devices, substances or related services or damages or compensation payable when the award or settlement does not specify the types of damages, have been fully exhausted.

Note: Damage awards or compensation payable for types of damage other than future care and, where future care has been distinguished, other than future care for drugs, devices, substances or related services, does not affect a beneficiary’s entitlement to benefits for the injury or illness giving rise to the need for the benefit.

Proof of eligibility

PharmaCare may require an individual to provide details of a damages award or compensation or to provide a copy of the court judgment or relevant sections of the settlement agreement. 

The individual may also be required to provide proof (through a notarized affidavit or other acceptable form) that the relevant portion of the damages award or compensation has been fully exhausted in order to be eligible for PharmaCare coverage for benefits for the treatment of the injury or illness in question.

Procedures for pharmacies

Processing an WorkSafeBC- or ICBC-covered prescription

1. Identify the patient as a WorkSafeBC /ICBC client.
   A WorkSafeBC /ICBC client should instruct the pharmacist that a prescription will be covered under a WorkSafeBC /ICBC claim.
2. Submit the intervention code DE on PharmaNet, which causes the claim to “Adjudicate to $0.00 as requested.”
   Although a WorkSafeBC /ICBC claim adjudicates to $0.00, the medication information is recorded on the patient medication history.
3. Follow the relevant WorkSafeBC /ICBC claim procedures or collect payment from the patient.

To process a federally-covered patient’s prescription

1. Enter the prescription as usual.
   PharmaNet returns an error message. The PharmaCare-paid amount is zero, but the patient’s medication history is updated.
2. Follow the relevant federal claim procedures or collect payment from the patient.

Permanently changing federal coverage on PharmaNet

PharmaCare Help Desk staff can add or remove a PHN from the Patient Coordination of Benefits Table when necessary. For example, if a person has retired recently from the Canadian Forces, the PHN can be removed from the Patient Coordination of Benefits Table.

To process patients with federal coverage changes

1. Call the PharmaCare Help Desk.
   The Help Desk will change the patient’s federal-coverage status in the Patient Coordination of Benefits Table.
2. Send the transaction to PharmaNet.

Medications not included in federal coverage

Sometimes federal coverage does not include a prescribed DIN/PIN, but PharmaCare does cover it. (For example, a veteran may have certain pensionable injuries and VAC will pay only for drugs related to those injuries.) In such situations, the PharmaCare Help Desk can temporarily change the patient status.

If federal coverage may be available on special authority, that process must be exhausted before contacting the Help Desk.

Note: PharmaCare does not cover methadone for Non-Insured Health Benefits (NIHB) clients. For more information, refer to Section 8.8—Methadone Maintenance Payment Program.

To obtain temporary coverage for federal patients

1. Call the PharmaCare Help Deskk.
   The Help Desk will change the patient status in the Patient Coordination of Benefits Table from “federally covered” to “not federally covered.”
2. Send the transaction to PharmaNet (including any applicable dispensing fee).
   After the transaction has been processed, the Help Desk will change the patient status back to “federally covered.”

To process federally covered non-residents

1. Enter the prescription on PharmaNet as usual (after assigning a PHN, if necessary).
   The prescription information will be included in the patient medication history and the claim will adjudicate with the PharmaCare portion as $0.00, as it would for any other non-B.C. resident.
   For more information on assigning a PHN for an out-of-province visitor, refer to Section 3.3—Pharmacist-assigned PHNs.
2. Follow the relevant federal claim procedures or collect payment from the patient.