6.1 Benefit Status Types
Last updated on December 16, 2024General Policy Description
PharmaCare uses an evidence-informed approach to drug policy development. By confirming that clinical evidence supports a drug or medical supply or device’s effectiveness before considering it for coverage, PharmaCare ensures the wise use of program resources.
Policy Details
PharmaCare considers a drug or medical device or supply for coverage upon receiving a request by the drug's manufacturer. After completing its review, PharmaCare decides whether a drug will be a full benefit, a partial benefit, a limited coverage benefit (covered only if a patient meets specific criteria) or a non-benefit (not covered).
Benefit status definitions
Each prescription drug or eligible medical supply or device is assigned one of four PharmaCare benefit status types:
| Benefit Status | Coverage Details | Notes |
|---|---|---|
| Regular benefit |
Eligible for full reimbursement subject to PharmaCare price limits and subject to the rules of a patient’s PharmaCare plan. |
|
| Partial coverage |
Eligible for limited reimbursement under the Low Cost Alternative Program or the Reference Drug Program or other maximum, and subject to the rules of a patient’s PharmaCare plan. |
In some situations, PharmaCare may grant full coverage through Special Authority to a drug that would otherwise be only a partial benefit. |
| Limited Coverage drug |
Eligible for reimbursement only in certain medical circumstances and subject to the rules of a patient’s PharmaCare plan. Before a patient can get PharmaCare coverage, their prescriber must submit a Special Authority request to PharmaCare. |
The drug is usually a second-, third- or fourth-line treatment. Drug is subject to LCA program rules if a low-cost alternative exists. |
| Non-benefit |
Not eligible for PharmaCare coverage. Special Authority is available only on an exceptional, last-resort basis, generally when all available PharmaCare benefit options have been tried without success or are unsuitable for the patient and no other coverage options are available (e.g., third-party insurance). If the drug subsequently becomes a benefit, PharmaCare cannot provide retroactive coverage. |
For a list of non-benefits, see What BC PharmaCare does not cover. |
- A prescription medication or medical supply may have a different benefit status under different PharmaCare plans.
- Patients wishing to take a partial benefit will be required to pay the difference between the Low Cost Alternative (LCA) or Reference Drug Program (RDP) price and the full cost of the prescription. For Fair PharmaCare patients, only the lower amount counts toward the annual deductible and family maximum, unless Special Authority has been provided.
Procedures for Pharmacists
Determining benefit status
There are several ways to determine the benefit status of a drug or supply:
- The online BC PharmaCare Formulary Search.
- The PharmaCare Newsletter routinely provides information on the completion of reviews, new benefits, and changes in benefit status.
- The Drug Review Results web page.
- Pharmacists can send the transaction through on PharmaNet to determine coverage and reverse the claim if necessary.
- Pharmacists may contact the PharmaCare Help Desk and choose either the interactive voice-response line, or hold to speak to a representative.
- Some in-pharmacy software stores benefit/non-benefit information.