General PharmaCare Coverage Policies
The following policies and programs may affect the portion of a prescription's cost that PharmaCare will cover. The cost of a prescription includes the drug cost and the pharmacy's dispensing fee.
Clinical Services Fees
PharmaCare pays the pharmacy a clinical services fee when a pharmacist renews or adapts a prescription for a B.C. resident. There is no charge to B.C. residents for these services.
Medication Review Services
PharmaCare also pays for pharmacist-delivered medication review services for eligible patients. Medication reviews help patients better understand how to manage the medications they take. Patients meet with their pharmacist to
At the end of the appointment, the pharmacist gives the patient a form that lists their medications. There is no charge to patients for this service.
See Section 8.9 — Medication Review Services of the PharmaCare Policy Manual for details.
Maximum Dispensing Fee Policy
Pharmacies charge a dispensing fee for each medication dispensed. PharmaCare sets a maximum dispensing fee that it will recognize. If a pharmacy charges more than the maximum dispensing fee recognized by PharmaCare, you will need to pay the difference in the cost unless the Full Payment Policy applies.
Frequency of Dispensing Policy
Effective February 1, 2009, PharmaCare limits the number of dispensing fees covered for prescriptions filled daily or in two- to 27-day supplies (unless the fill is for the full amount prescribed).
For daily dispensing, the maximum number of fees PharmaCare covers is one fee per drug, per day up to a maximum of three dispensing fees.
For a two- to 27-day supply, the maximum number of fees PharmaCare covers is one fee per drug, per day up to a maximum of five dispensing fees.
Unless your health care practitioner has ordered the medication to be dispensed frequently, to qualify for coverage of dispensing fees for the frequent dispensing, you must sign a form that the pharmacy will provide. The pharmacy will notify your physician and keep the signed form on file to document the reason for frequent dispensing.
Trial Prescription Program
The Trial Prescription Program encourages the dispensing of a small quantity (10 to14 days’ supply) of expensive medications that have a high incidence of side effects. Dispensing a small quantity when you first start taking a drug prevents medication being wasted if you do not tolerate the drug well.
PharmaCare reimburses the pharmacy for the initial dispensing fee for the trial quantity—you pay only the portion of the drug costs not covered under your PharmaCare plan rules. When you have the balance of the prescription filled, you pay your portion of the remaining drug cost and the dispensing fee, according to your PharmaCare plan rules.
To determine which medications to include in the Trial Prescription Program, Pharmaceutical Services Division consults with the College of Pharmacists of B.C. and the BC Pharmacy Association.
Our Trial Prescription Program page provides a list of the drugs eligible for coverage of an additional dispensing fee.
Full Payment Policy
The policy applies when both the following apply:
* Patients covered by any PharmaCare plan receive 100% coverage of eligible costs under their plan—except those who have not yet met their Fair PharmaCare family maximum. Please see the following question for more information.
If a pharmacy mistakenly charges you when the Full Payment policy applies, they must refund those charges to you.
Are there circumstances under which a pharmacy CAN charge me more than the maximums PharmaCare has set?
Yes, a pharmacy can charge you above the maximum if
A pharmacy can also charge you above the maximums if the drug or product
Can a pharmacy charge my private insurer?
If a pharmacy is able to determineat the time your medication is dispensed that your private insurer will cover any costs in excess of the amount PharmaCare covers, the pharmacy can charge your private insurer. Please note that a pharmacy cannot charge a patient on the understanding that your private insurer may pay all or some of the cost at a later date. The determination of coverage by your private insurer must be made at the time the medication is dispensed.
When you are covered by two or more PharmaCare Plans
If you covered under more than one PharmaCare plan, some of your drugs may be subject to the Full Payment Policy while others are not.
For example, Robert is covered under Fair PharmaCare and under the No-Charge Psychiatric Medication Plan (Plan G). Robert has two prescriptions to fill. One is for a psychiatric drug covered under Plan G. The other is for a skin ointment covered under Fair PharmaCare.
Since Plan G provides 100% coverage of the eligible costs of the psychiatric drug, the prescription is subject to the Full Payment Policy and Robert will not be charged any additional amount for the drug.
The prescription for the ointment willnot be subject to the Full Payment Policy. This is because, although Robert has met his Fair PharmaCare deductible, he has not reached his Family Maximum, so PharmaCare is covering only 70% of his drug cost, not 100%. Robert will have to pay the amount PharmaCare does not cover (30%) and any amount the pharmacy charges in addition to that.
How do I know if I have met my family maximum?
You can call Health Insurance BC. Your pharmacist may also be able to tell you if PharmaCare is covering 100% of the PharmaCare eligible portion of your prescriptions.
Maximum Pricing Policy
PharmaCare sets a maximum price it will recognize for each drug. If the drug cost your pharmacy claims exceeds this maximum price, you will need to pay the additional cost unless the Full Payment Policy applies.
Low Cost Alternative (LCA) Program
PharmaCare's Low Cost Alternative (LCA) Program focuses coverage on lower-priced (usually generic) drugs. Generic drugs have the same active ingredients and deliver the same health benefits as brand name drugs. Buying a lower-priced generic drug does not compromise care.
The LCA Program lowers PharmaCare costs, protecting PharmaCare for the long term. If you do not have 100 % coverage through a government or private drug insurance plan, buying lower-cost drugs can also reduce the amount you pay out of your own pocket.
How it Works
Under the program, drugs – usually generic drugs – are placed in LCA categories based on the drug, strength and formulation. PharmaCare sets a maximum amount it will reimburse for the drugs within each LCA category (the “LCA price”).
The maximum reimbursement amount for each LCA category is usually based on the price of the least expensive product in the category that is available in British Columbia. PharmaCare does not cover generic products that cost more than the maximum amount PharmaCare accepts for the category.
Some brand products may be partially covered up to the LCA price for the category. If you are prescribed a drug that is not covered or is only partially covered you can choose to:
If you cannot take a low-cost alternative because you are allergic to one of its non-medicinal ingredients, your health care practitioner can request Special Authority coverage for another drug in the category.
For more information, click here.
Reference Drug Program
If there is more than one drug in a therapeutic class (i.e., a group of drugs used to treat the same condition), PharmaCare provides full coverage of only those drugs considered to be the most medically effective and the most cost effective in that category. This drug is called the "reference drug.'" Reference drugs are normally the drugs considered to be the standard first treatment of choice.
Five classes of drugs are included in the Reference Drug Program:
For the lists of the drugs included in each class of drugs, see our Reference Drug Program section.
If you cannot take the reference drug, your health care practitioner can request Special Authority coverage of another drug in the category.
Maximum Days' Supply Policy
For short-term drug prescriptions and first-time prescriptions for longer-term "maintenance" drugs, PharmaCare coverage is limited to a maximum 30 days’ supply.
When you refill a prescription for a drug intended for longer term use, PharmaCare limits coverage to a 100-day supply.
Short-term medications include antibiotics, sedatives, sleeping pills and barbiturates, some of which are addictive or become ineffective if used over a long period of time.
Maintenance drugs include those used for chronic conditions such as diabetes and Parkinson's Disease.
Exemptions are available for residents of rural or remote areas without a pharmacy nearby.
Coverage of Early Fills of Medication
PharmaCare may not cover a prescription if you still have more than a two-week supply of the drug.
This helps to eliminate the dangers of having excess medication on hand. It also avoids waste, especially in cases in which a physician discontinues your medication while you still have a large supply. In such cases, the drug and any portion of the cost paid by you and by PharmaCare is wasted. Also, if you do not dispose of the medication correctly, it may harm the environment. (For more information on the safe disposal of unused medications, visit your local pharmacy.)
If you choose, you may still have the prescription filled or refilled while you still have more than a two-week supply, but PharmaCare will not cover any portion of the cost.
Note: In some cases, after consultation with your pharmacist and perhaps with your physician, it may be determined that an early fill of your prescription is appropriate. In this case, PharmaCare would cover the eligible costs.
Travel Supply Policy
PharmaCare does not usually cover a prescription claim if you have more than 14 days’ supply left from the previous fill of the medication. However, PharmaCare allows you to fill a prescription earlier if you need a supply for travel outside B.C.
Once every six months (180 days), if you are travelling out of province, you can top up your existing prescription supply to the maximum days’ supply recognized by PharmaCare as described below:
For your travel supply to be eligible for PharmaCare coverage, you must complete and sign a Travel Declaration form (supplied by your pharmacy) on the date your prescription(s) is filled.
If you request more than the PharmaCare maximum days’ supply limit, only the maximum days’ supply will be eligible for coverage and you will be responsible for any remaining cost.
If you are covered under the Fair PharmaCare plan, only the portion of your prescription(s) eligible for PharmaCare coverage will count towards your deductible and/or family maximum.
Drugs Requiring Pre-Approval
Limited Coverage Drugs
Limited coverage drugs are medications not generally considered to be the standard first treatment of choice or are medications for which more cost‑effective alternatives exist.
PharmaCare provides access to the drugs when medical circumstances warrant through its Special Authority process, described in the next section of this page.
If you have a medical need for a drug included in the Limited Drug Coverage Program, your health care practitioner can submit a Special Authority request to PharmaCare explaining your medical need.
» To find out which drugs PharmaCare covers and which drugs require Special Authority, use our online Formulary Search.
Drugs requiring "Special Authority" coverage
A Special Authority grants full benefit status to a medication that would otherwise be a partial benefit or a limited coverage drug. All requests for Special Authority coverage must be submitted by your health care practitioner.
Special Authorities are normally granted for a specific drug for an individual patient. In some cases, a Special Authority exemption may be granted to a physician or a physician specialty group Exemptions provide coverage of a specific drug for all patients of a physician or specialty group.
Actual coverage is based on your usual PharmaCare plan rules, including any deductible requirement. If you receive Special Authority coverage for a drug, it may still be subject to the rules of the Low Cost Alternative Drug Program, Reference Drug Program and the PharmaCare Maximum Days' Supply and Maximum Pricing Policy still apply.
Special Authority coverage begins the day the information is entered into PharmaNet, the B.C. computer network that links all BC pharmacies to a central set of databases. Depending on the individual drug, Special Authority coverage may be for a limited time (for example, six months) or be indefinite.
To be eligible for coverage, Special Authority must be in place before you purchase a drug. Coverage cannot be provided retroactively.
The following categories of drugs require Special Authority approval before the prescription is purchased.
To find out if your drug requires Special Authority, use our online Formulary Search.
The following categories of drugs are not eligible for Special Authority: