7.7 Psychiatric Medications (Plan G)

Regular Plan G coverage is available to individuals of any age, who:

• meet the plan’s clinical and financial criteria (details below)
• are residents of B.C. with active Medical Services Plan (MSP) coverage¹

Coverage is for individuals, rather than families.

Plan G provides 100% coverage of eligible drug and dispensing fee costs (up to the maximum cost and dispensing fee recognized by PharmaCare) for certain psychiatric medications to individuals for whom the cost of these medications is a serious barrier to treatment.

Plan G assistance is not available to

• individuals living in long-term care facilities that are enrolled in Plan B (Plan B already fully covers psychiatric medications)
• individuals in acute care or extended care hospitals
• individuals with employer-sponsored drug coverage benefits
• individuals whose drug costs are covered by federal insurers

Clinical eligibility 

For the patient to meet clinical eligibility requirements:

• A practitioner* must assess them, and
• Prescribe them a drug covered under the Plan G formulary, and
• Certify (on the HLTH 3497 - Application for PharmaCare Plan G (PDF, 896KB)) that:
  • The patient has been hospitalized for treatment related to a psychiatric condition; OR
  • Without prescribed psychiatric medication, the patient is likely to be hospitalized for a psychiatric condition; OR
  • Without prescribed psychiatric medication, the patient, or another person, is likely to suffer serious physical or psychological harm or economic loss

*The prescribing practitioner must have a valid practitioner college ID from a B.C. or Alberta regulatory college. Their practitioner ID must have been added to and verified in PharmaNet. This is done automatically for registrants of B.C regulatory colleges, and can be done by request for registrants of Alberta regulatory colleges.

Practitioners can contact the PharmaCare Help Desk to ask about the status of their practitioner ID in PharmaNet or request that their ID be added (for Alberta registrants).

Financial eligibility

In addition to meeting clinical criteria, applicants must sign a declaration on the HLTH 3497 - Application for PharmaCare Plan G (PDF, 896KB) that:

• The cost of prescribed psychiatric drug(s) is a barrier to treatment and that they have no other financial coverage for the drug(s); and
• They are eligible for supplemental services under MSP, i.e., have an adjusted family net income of $42,000 or less.

Applying for regular Plan G

To apply for regular Plan G coverage:

1. The patient and their practitioner complete the HLTH 3497 - Application for PharmaCare Plan G (PDF, 896KB).
2. The practitioner faxes the application to a mental health and substance use centre (MHSUC) or a Child and Youth Mental Health service centre (CYMH) OR the patient delivers the application in person to the relevant site.
3. The local MHSUC or CYMH verifies eligibility and faxes the application to Health Insurance BC (HIBC) to register the patient. Note:  PharmaCare cannot independently confirm eligibility for, nor register a patient for, regular Plan G coverage.

Regular Plan G coverage is for a set period of no more than 1 year. When this period expires, the practitioner may re-apply for another year of coverage. The local MHSUC may notify the individual at the address on their Plan G application of the expiry of their Plan G coverage and the need to see their practitioner to re-apply. If no address is provided, the individual cannot be notified.

Applying for Plan G bridge coverage – urgent after-hours situations

Plan G bridge coverage is a temporary, expedited period of coverage available in urgent after-hours situations. The following facilities can apply for bridge coverage on behalf of their clients:

• Emergency departments (EDs)
• Rapid access addiction clinics (RAACs)
• Urgent and Primary Care Centres (UPCCs)
• Correctional facilities (both provincial and federal)
• Public facilities in B.C. offering substance use withdrawal management (WDM) services through health authorities

Bridge coverage enables access to medications until a client and a prescribing practitioner can apply for regular Plan G coverage. Prescribers should encourage patients to get regular Plan G coverage in place before the 3-month period is up.

To apply for Plan G bridge coverage:

1. The patient and their practitioner complete the HLTH 3497 - Application for PharmaCare Plan G (PDF, 896KB).
2. The practitioner faxes the application directly to HIBC. The local MHSUC or CYMH does not need to verify or process the application.

Bridge coverage is for 3 months from the date the application is processed by HIBC. To maintain Plan G coverage, patients should meet with a prescriber in their community as soon as possible (i.e., within 10 weeks) to apply for regular Plan G coverage (if needed).

Previous Plan G bridge coverage does not affect a bridge coverage application—a practitioner can apply for it again for a patient who previously had bridge coverage and is again in urgent health circumstances.

Practitioners at locations eligible for bridge coverage may also submit applications for regular Plan G coverage.

Note: A practitioner may apply for exceptional coverage and bridge coverage for the same patient at the same time with a single form, sent directly to HIBC.

Applying for exceptional coverage – for patients without MSP coverage yet

Plan G coverage may be extended to new residents of B.C. who have not yet enrolled in MSP.

To apply for exceptional coverage:

1. The patient and their practitioner complete the HLTH 3497 - Application for PharmaCare Plan G (PDF, 896KB)
2. The practitioner completes section C of the application and certifies that:
   1. They have advised the patient that exceptional Plan G coverage is for up to 6 months with no possibility of renewal or extension and that;
   2. The patient has either applied for MSP and is waiting to be fully enrolled, or the patient understands that they must apply for MSP without delay

Note: A practitioner may apply for exceptional coverage and bridge coverage for the same patient at the same time with a single form, sent directly to HIBC.

Individuals unwilling or unable to sign an application for Plan G coverage

If an individual is unable to sign Section A of the HLTH 3497 - Application for PharmaCare Plan G (PDF, 896KB) but is willing and able to make a verbal declaration, the practitioner (or a staff member at an MHSUC or CYMH) may sign the form for them, with the indication that they witnessed a verbal declaration. This is also permitted in situations where the practitioner and the patient are in different physical locations, e.g. a telemedicine appointment.

If an individual is unwilling to sign Section A of the Application for PharmaCare Plan G, it can be signed only by a person legally empowered to act on the individual’s behalf. This person must be one of the following:

• A member of a committee appointed under the Patients Property Act
• A person acting under power of attorney
• A representative acting under a representation agreement under the Representation Agreement Act

>> For more information, see page 2 of HLTH 3497 - Application for PharmaCare Plan G (PDF, 896KB).

The MHSUC or CYMH provides eligibility information to PharmaCare. Coverage starts the day the information is entered in PharmaNet.

Plan G coverage cannot be provided retroactively.

Regular Plan G coverage is for up to 1 year. Bridge coverage is for 3 months, but can be provided several times to the same patient. Exceptional coverage is provided for 6 months once only.

MHSUCs and CYMHs are not permitted to automatically renew Plan G coverage.

Renewal of Plan G coverage

If an individual’s Plan G coverage is close to expiring, the MHSUC or CYMH may contact the individual to confirm their continuing need for Plan G coverage and, if appropriate, initiate a visit with a practitioner to enable renewal of coverage in time to prevent a lapse in coverage. 

If the renewal process is not completed before the individual’s Plan G coverage expires, coverage terminates without any additional notification.

The renewal of Plan G coverage requires an application and eligibility assessment in the same manner as for initial coverage. The clinical and financial eligibility criteria for renewal are identical to those for initial coverage.

Plan G covers the medications listed in the Plan G formulary.

Drugs in the formulary identified as "Limited Coverage" require prior Special Authority approval from PharmaCare. For these medications, an individual's practitioner must submit a Special Authority Request to PharmaCare, unless a prescriber/specialty/pharmacy exemption is in place.

Items not covered under Plan G are automatically adjudicated under the individual’s primary PharmaCare plan (e.g., Fair PharmaCare, Plan C or Plan F).

1. Check the patient's identification
2. Patients registering for Plan G with an MHSUC or CYMH should have been instructed by staff to provide their PHN, as well as a second piece of identification that meets the College of Pharmacists of BC guidelines. 
   >> Refer to Section 9.1—Positive Identification of Patients.
3. If necessary, verify a patient’s identity, including their PHN, with the local MHSUC or CYMH staff
4. Process the prescription as usual

The PharmaNet transaction will not provide the expected adjudication results if the coverage has not been entered.

1. Call the PharmaCare Help Desk.
2. The Help Desk will confirm whether an Application for PharmaCare Plan G has been received but not yet entered in PharmaNet, received and returned as incomplete, or not received.
3. Refer the patient to their practitioner or local MHSUC or CYMH if the Help Desk has not yet received an application form.