6.1 Benefit Status Types

General Policy Description

PharmaCare uses an evidence-informed approach to drug policy development. By confirming that clinical evidence supports a drug’s effectiveness before considering it for coverage, PharmaCare ensures that program resources are wisely spent.

Policy Details

Benefit status definitions

Each prescription drug or eligible medical supply or device is assigned one of four PharmaCare benefit status types:

Benefit status definitions
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 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 medical practitioner 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 under any circumstances.

Special Authority is not available for these drugs.

If the drug subsequently becomes a benefit, PharmaCare cannot provide retroactive coverage.

For a list of non-benefits, see the Examples of Items/Services that 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 by PharmaCare.

Procedures for Pharmacists

Determining benefit status

There are several ways to determine the benefit status of a drug or supply:

  • Use the online PharmaCare Formulary Search.
  • The PharmaCare Newsletter routinely provides information on the completion of reviews, new benefits, and changes in benefit status.
  • Use the Drug Review Results web page for drugs under review.
  • Pharmacists can send the transaction through on PharmaNet to determine coverage and reverse the claim if necessary.
  • Pharmacists may contact the PharmaNet Help Desk and choose
    • the PharmaCare Information Linethis interactive voice-response system can provide information regarding the benefit status and benefit plans for a given drug.
    • to speak to a service representative.

>> For more information, see PharmaCare contacts.

  • Some in-pharmacy software provides the ability to store benefit/non-benefit information.

Tools and Resources