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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.
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.
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.
Maximum Pricing Policy
When pharmacies submit drug claims to PharmaCare, they claim only their actual acquisition cost for the drug. To ensure claims reflect a reasonable actual acquisition cost, 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.
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:
- PharmaCare coverage of the first fill of an eligible drug intended for long-term use—and the first fill/refill of a prescription for an eligible drug intended for short-term use—is limited to a 30-day supply.
- PharmaCare coverage for each refill of a prescription for an eligible drug intended for long‑term use is limited to a100-day supply.
For your travel supply to be eligible for PharmaCare coverage, you must complete and sign a Travel Declaration form (supplied for 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.
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.
Low Cost Alternative Program
PharmaCare's Low Cost Alternative Program focuses coverage on lower lower-priced, usually generic, drugs.
If several drugs contain identical active ingredients, PharmaCare sets a maximum "Low Cost Alternative (LCA) price" it will cover for any of those drugs. The LCA price for the drugs is set at the lowest average price being claimed by B.C. pharmacies. If the drug you choose is below that price, it is fully covered. If it is above the LCA price, PharmaCare does not cover the additional cost.
So, if your health care practitioner prescribes a drug that is included in the Low Cost Alternative program, you have the choice of buying:
- a low cost alternative—which is a full benefit according to the usual rules of your PharmaCare plan, or
- the partial benefit drug—which will be eligible for only partial coverage (up to the LCA price). When you purchase a partial benefit, you pay the difference in the cost.
Drugs that have identical active ingredients provide the same health benefits, so purchasing a lower priced version makes sense: It helps to keep PharmaCare sustainable and helps British Columbians who pay some, or all, of their own drug costs to save money too.
If you cannot take a low cost alternative because you are allergic to one of the non-medicinal ingredients, your health care practitioner can request Special Authority coverage of 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:
- histamine 2 receptor blockers (H2 blockers)
- non-steroidal anti-inflammatory drugs (NSAIDS)
- nitrates
- angiotensin converting enzyme inhibitors (ACE inhibitors)
- dihydropyridine calcium channel blockers (dihydropyridine CCBs).
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.
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.
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.
If you know the generic name of a drug, you can check our Limited Coverage Drug Program page to see if it requires Special Authority. If you do not know the generic name, you may find it on our Brand Name/Generic Name Cross-Reference page.
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.
The following categories of drugs are not eligible for Special Authority:
- Drugs included as part of a private clinical trial
- Smoking cessation aids
- Diet therapy
- Drugs classified as or used for cosmetic purposes
- Drugs still under review by PharmaCare.
Last Revised: July 10, 2008
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