4.2 Manual Patient Claims
[July 2019: Updated to clarify and permit faxed patient-pay manual claims]
General Policy Description
PharmaCare claims may be submitted by the patient. The provider is encouraged to assist the patient in filing the claim.
A patient's PharmaCare claim may cover multiple receipts if all purchases were made within a single calendar year. Claims must be submitted before March 31 of the year immediately following the benefit purchase.
Manual patient claims may also be submitted with a patient-signed letter containing the patient's full name, birth date, Personal Health Number (PHN), and address.
To assist a patient in filing a Fair PharmaCare claim:
- Collect the full cost of the prescription or item from the patient.
- Provide the patient with a receipt clearly showing itemized costs, and provider name and address.
The patient should complete the claim form or letter and affix the receipt(s).
- The provider or patient may forward the claim to PharmaCare at the address listed on the claim form or fax it (including receipts) to HIBC. If the fax number is secure and private and the patient or provider wishes to receive follow-up communication by fax, please note “PRIVATE FAX” on the submission. All receipts must be clearly visible on the fax.
Processing of patient Fair PharmaCare claims
HIBC processes Fair PharmaCare claims on PharmaNet. The PharmaCare portion of each claim, if any, is remitted to the patient by a cheque issued by the Ministry of Finance.
In a separate mailing, the claim—and all submitted receipts—is returned to the patient along with a PharmaCare Statement detailing what portion of the cost of each submitted receipt PharmaCare will cover as well as the total amount of the cheque.
A patient covered by a third-party insurer may then use the returned receipts and PharmaCare Statement to submit a claim to the insurer.
If a claim is faxed from a private and secure fax, any follow-up communication, including the resulting PharmaCare Statement, may be faxed to the patient or provider by HIBC.
If a Fair PharmaCare patient’s annual deductible has not yet been met, some (or all) of the claim amount for an eligible benefit will accumulate towards that deductible/family maximum.