1. What Does it Really Mean?
Pharmacare Tie-In
What
Does it
Really Mean?
During the last round of negotiations a number of Collective Agreements added a PharmaCare Tie-In to the Extended Health Plan.
This has resulted in a lot of member confusion about what effect this will have on the level of benefits they will receive in the future.
In anticipation of the changes, we are suggesting that members meet with their doctors to determine whether a change in prescribed drugs or application for a Special Authority is needed and/or appropriate.
This presentation contains information that may be helpful for members and staff related to PharmaCare and its various components.

2. Changes to the Extended Health Drug Coverage for Groups Moving to a PharmaCare Tie-In
No Impact
If your drug is included on the BC Pharmacare formulary you will not see a difference in the coverage under your extended health plan.
A fairly large percentage of members will not see a difference in the coverage as the drugs they are prescribed are on the PharmaCare formulary.

3. To find out if a drug is on the Pharmacare formulary:
The BC Government website contains a search engine where one can find out if a drug they have been prescribed in the past is covered, needs a Special Authority or is not covered at all.

4. Clicking on "Search the PharmaCare Formulary" takes you to a screen where you enter the name of the drug you are checking on. For an example - if you enter the brand name "tecta", check "Give me a summary of the medications that match my search criteria" you go to a screen with..

5. A search for "Tecta" brings up pantoprazole magnesium.
The generic drug name "pantoprazole magnesium". If you click on the generic drug name you are redirected to the summary for that drug.

6. When you click on the drug name you get the summary below:
The summary looks like this - it gives information related to reference numbers, brand name and strength, the form of the drug maximum supply and PharmaCare coverage as well as telling you if you need a special authority.
Clicking on "Yes" under the column titled "Special Authority Needed" will take you to a page that contains information specific to the available special authorities for that particular drug.

7. Special Authority Needed:
Some drugs require Special Authority from BC PharmaCare before they will be covered under PharmaCare and therefore by your Extended Health Plan.
There is no retroactive coverage. You must have a Special Authority in place before filling a prescription for it to be covered.
You must provide a copy of the Special Authority to the carrier (Pacific Blue Cross, Manulife, etc.) before they will reimburse you for the drug.
Don't know if you have a Special Authority?
Call Health Insurance BC at or
Post Secondary Support has negotiated retroactivity for coverage of Special Authorities, but this is the only sector that has this agreement.
If you do need Special Authority to have the specific drug covered by PharmaCare and therefore by the Extended Health Plan, you have to obtain the Special Authority before having a prescription filled. PharmaCare will not provide coverage retroactively, and neither will the Extended Health Plan cover the cost without having received a copy of the approval on file.
Special Authorities may be time limited, or be in place for an indefinite period of time. If it is time limited and you must get a new approval, then you will have to provide a copy of the new document to your extended health carrier.

8. The Ministry of Health Website:
This site contains a cross referenced list of drugs that require Special Authority and links to the information specific to obtaining one for each drug:
Brand Name Drug: Tecta
Generic Drug: pantoprazole magnesium
You can also find more detailed information regarding special authorities that may be granted by PharmaCare on this site.

9. How to Access the BC Pharmacare Special Authority Program: STEP 1:
Make sure you are registered for Fair Pharmacare. If you are not registered, you can register online or by telephone: or
Call or (toll free)
Monday - Friday 8:00 a.m. to 8:00 p.m. and Saturday 8:00 a.m. - 4:00 p.m.
Members should be encouraged to register for Fair PharmaCare This can be done online or via telephone.

10. Step 2:
Your doctor applies to Pharmacare for a Special Authority on your behalf
You should not be charged by your doctor for this service.
All forms must be completed by a licensed physician
and are available online at:
Your doctor will fax the
completed request to the
number shown on the form.
Only doctors may apply for a Special Authority. Because of the increase in requests for this service many doctors are now charging a fee to complete the application form and submit it for their patients. The Health Sectors represented by HEABC have an agreement to have this new charge reimbursed through the Extended Health Plans, but most other plans do not pay for it.

11. Step 3:
Pharmacare will notify your doctor of their decision in writing.
You should ask for a copy of the decision document either from your doctor or directly from Pharmacare.
Ensure that you provide a copy of the approved Special Authority to your extended health plan carrier. You should only have to provide a copy of the decision once per approved period.
Once a decision has been made, PharmaCare notifies the applying doctor of its decision. If approved, the doctor should provide a copy to the patient. Members must also provide a copy of the approval to the extended health carrier for their files before they will cover the cost. If the approval is for an indefinite period there is no need to send in another copy each time a prescription is filled. If, however, there is a time limit on the approval, then each time the special authority is renewed a new copy must be given to the carrier.

12. Special Authority Process Overview
Physician, dentist or hospital pharmacist submits Special Authority request to PharmaCare
By fax to
Monday to Friday 8 a.m. to 8 p.m.
PharmaCare assigns a priority level to the request
URGENT
PRIORITY
REGULAR
Decision within one business day
Decision within two business days
Decision within 10 business days
APPROVED
DENIED
NOT APPROVED - more info required
Decision communicated to applicant by fax/mail
Medication designated as a full benefit subject to the usual PharmaCare plan rules and deductible and copayment requirements
Returned to physician, dentist or hospital pharmacist

13. If your drug is not included on the BC Pharmacare Formulary:
You may opt to use the drug, but you will not be reimbursed by your Extended Health Plan.
Or you can ask your doctor to prescribe an alternative drug that is covered under the PharmaCare formulary.
Some common drugs that are not covered:
Victoza (liraglutide)
Ezetrol (ezetimibe)
Xolair (omalizumab)
Singulair (montelukast)
Cymbalta (duloxetine)
Pristiq (desvenlafaxine)
Lyrica (pregabalin)
Diane 35
Tramacet (tramadol/acetaminophen)
Compounded products with ingredients not covered by BC PharmaCare
Vyvance
If a prescribed drug is not covered at all by PharmaCare, the member must either ask their doctor if there is an alternate drug that will work as well, and is covered by PharmaCare, or be prepared to pay the full cost of the drug themselves.
Again, Post Secondary Support has reached an agreement to allow the parties to consider directing the carrier to cover drugs that are not under the PharmaCare formulary - on an exceptional basis. If there is no alternative, covered drug, the member must ask their doctor to write a letter to the parites explaining why the drug needs to the one used. The parties review the information and may agree to direct the plan carrier to provide coverage to the member for th e drug on an ongoing basis.

14. Low Cost Alternative (LCA) and Reference Based Drug (RDP) Programs:
LCA categories consist of multi-source drugs sharing the same active ingredient (chemical entity) recognizing the strengths and dosage forms that provide the best value.
Unlike the LCA Program, the RDP applies to different drugs (chemical entities) in the same therapeutic category.
Links to Pharmacare's Low Cost Alternative (LCA) and Reference Drug Program (RDP) Data Files can be found at:
LCA Master Spreadsheet: Includes all new and existing generic drugs within the LCA program with their current reimbursement limits.
RDA Master Spreadsheet: Includes all new and existing drugs within the RDP program with their current reimbursement limits.
LCA /RDP Updates Workbook: Includes four spreadsheets that provide cumulative information on all new generic drug listings, all new LCA categories, all changes and effective dates for new LCA or RDP reimbursement limits, and any drug de-listings.
PharmaCare has implemented several programs intended to reduce costs of prescription drugs - the Low Cost Alternative and Reference Based Drug programs do this by limiting the amount that will be paid for by PharmaCare.
The spreadsheets on this slide may not be terribly helpful to most members, but do provide information tha some may want to access.

15. Low Cost Alternative Drug Program (LC): bases PharmaCare coverage on the price of the lowest cost brand among those drugs that have identical active ingredients.
If a drug is, or would be, part of an LCA category, the following applies:
Full Benefits: These products are priced at or below the LCA price for the category. They adjudicate at the lesser of the Pharmacare maximum price for the product or any applicable Reference Drug Program (RDP) price.
Partial Benefits: These are usually brand name products (exceptions are noted in the LCA Data Files) within an LCA category priced above the LCA price. They adjudicate at the lesser of the LCA price, the Pharmacare maximum price for the product, or any RDP price applicable to the product. The patient is required to pay any portion of a drug's cost that exceeds the LCA price (or RDP price, if applicable).
Non-Benefits: Generic drugs that are priced above the maximum accepted list price are not covered by Pharmacare. This includes products discontinued by the manufacturer.
If there is no designated LCA category for a benefit drug (on the formulary), it is covered under existing Pharmacare policies.
If a drug is not listed on the formulary, it is not covered at all.

16. Reference Based Drug Program (RDP): applies to drugs that are not identical but are part of the same drug category and are used to treat the same conditions.
For most common medical conditions, drug manufacturers market a wide variety of similar prescription drugs that often vary greatly in price but achieve the same medical effect.
Under the RDP, PharmaCare coverage is based on the cost of the reference drug or drugs in a therapeutic category. This is the drug(s) considered to be equally effective and the most cost effective in that category. The RDP currently applies to five classes of drugs:
Histamine 2 receptor Blockers (H2 Blockers),
Non-Steroidal Anti-inflammatory drugs (NSAIDS),
Nitrates,
Angiotensin Converting Enzyme Inhibitors (ACE inhibitors), and
Dihydropyridine Calcium Channel Blockers (Dihydropyridine CCBs).

17. Reference Based Drug Program, continued
Under this program, PharmaCare obtains independent, expert advice on which prescription drug products within a group of similar medications are equally safe and beneficial, and the most cost-effective.
The cost of the preferred drug will then be the price of the "reference drug" for the level of coverage that PharmaCare will establish for any medication in that class used to treat that condition.
Patients eligible for PharmaCare benefits will receive full coverage for the preferred "reference" prescription drug, or may choose a more expensive drug and pay only the difference in price.
If a patient needs a more expensive drug for medical reasons, their doctor may obtain Special Authorization from PharmaCare for full coverage of that drug.

18. Fair Pharmacare: How does it fit in?
PharmaCare Annual Family Deductible: You are responsible for 100% of costs until your eligible prescription and medical supply costs reach your deductible. Once your family meets this amount, PharmaCare assists by paying a percentage of further eligible expenses for the rest of the calendar year.
Your Extended Health Plan (EHP): once you have met the annual EHP deductible your plan will cover the cost that you must pay for these prescriptions up to the limits contained in the plan. (e.g. many plans have an 80% co-insurance that either reimburses 80% of the cost or provides direct pay drug benefits to 80% of the total cost).
The dispensing fees are also covered, but you need to be aware of whether there is a cap to the amount covered by your EHP. (e.g. some plans cap these fees at the PharmaCare maximum which is $10 per prescription for 2013)

19. When you reach your Fair PharmaCare Annual Family Deductible:
Fair PharmaCare will pay a portion of your prescription and medical supply costs after you reach your annual family deductible. You and/or your EHP will pay only the remaining portion of the cost. For example, if the PharmaCare portion is 70%, you (and/or your EHP) would need to pay the remaining 30% of your eligible prescription costs until you reach your Annual Family Maximum.
Your Extended Health Plan (EHP): Will cover the remaining 30% of eligible prescription costs, reimbursed at the level contained in your EHP.
Example: A family with a combined income of $40,000.00
will have an annual family deductible of $1,
Once they have paid for (or had covered by their EHP) $1200 of prescriptions and medical supplies, PharmaCare will cover 70% of future costs (with a maximum dispensing fee of $10) and the other 30% will be paid through the EHP at the levels contained in the plan.

20. When you reach your Fair PharmaCare Annual Family Maximum:
Our example family will have an annual family maximum of $1,
Once they have met their annual family maximum of for the year, PharmaCare will cover 100% of their eligible prescription and medical supply costs, again with a maximum $10 dispensing fee per prescription, for the rest of the calendar year.
If PharmaCare covers 100% of the cost then your EHP does not pay any part of the cost.

21. PDF file showing Annual Deductibles by Net Income can be found at:
Family Net Income Range
Family Deductible
Portion PharmaCare pays after deductible is met
Family Maximum PharmaCare covers 100% of costs for the rest of the year after the maximum is met
$0.00
$1,875.00
70%
$25.00
$1,875.01
$3,125.00
$50.00
$3,125.01
$4,375.00
$75.00
$4,375.01
$6,250.00
$100.00
$6,250.01
$8,750.00
$150.00
$8,750.01
$11,250.00
$200.00
$11,250.01
$13,750.00
$250.00
$13,750.01
$15,000.00
$300.00
$15,000.01
$16,250.00
$450.00
$16,250.01
$18,750.00
$350.00
$525.00
$18,750.01
$21,250.00
$400.00
$600.00
$21,250.01
$23,750.00
$675.00
$23,750.01
$26,250.00
$500.00
$750.00
$26,250.01
$28,750.00
$550.00
$825.00
$28,750.01
$30,000.00
$900.00
$30,000.01
$31,667.00
$1,200.00
$31,667.01
$35,000.00
$1,000.00
$1,350.00
$35,000.01
$38,333.00
$1,100.00
$1,475.00
$38,333.01
$41,667.00
$1,600.00
$41,667.01
$45,000.00
$1,300.00
$1,750.00
$45,000.01
$48,333.00
$1,400.00
$48,333.01
$51,667.00
$1,500.00
$2,000.00
$51,667.01
$55,000.00
$2,150.00
$55,000.01
$58,333.00
$1,700.00
$2,275.00
The information on this slide and the next one is taken from the site shown here

22. If you have not filed income tax returns or are not registered for Fair PharmaCare your annual family deductible is $10, only after you have met this deductible will PharmaCare will pay 100% of the eligible costs.
Family Net Income Range
Family Deductible
Portion PharmaCare pays after dedcuctible is met
Family Maximum PharmaCare covers 100% of costs for the rest of the year after the maximum is met
$58,333.01
$61,667.00
$1,800.00
70%
$2,400.00
$61,667.01
$65,000.00
$1,900.00
$2,550.00
$65,000.01
$70,833.00
$2,000.00
$2,675.00
$70,833.01
$79,167.00
$2,250.00
$3,000.00
$79,167.01
$87,500.00
$2,500.00
$3,350.00
$87,500.01
$95,833.00
$2,750.00
$3,675.00
$95,833.01
$108,333.00
$4,000.00
$108,333.01
$125,000.00
$3,500.00
$4,675.00
$125,000.01
$141,667.00
$5,350.00
$141,667.01
$158,333.00
$4,500.00
$6,000.00
$158,333.01
$183,333.00
$5,000.00
$6,675.00
$183,333.01
$216,667.00
$8,000.00
$216,667.01
$250,000.00
$7,000.00
$9,350.00
$250,000.01
$283,333.00
$10,000.00
$283,333.01
$316,667.00
$9,000.00
$316,667.01
$999,999,999.00
100%
Deductible for a family registered for Fair PharmaCare whose income cannot be verified
Deductible for a person actively enrolled in the Medical Services Plan but not registered for Fair PharmaCare
Fair PharmaCare deductibles and maximums are based on one's income 2 years ago.
If someone is not registered, they are given the highest deductible possible.
Pacific Blue Cross sends out letters to members who are nearing $1,000 of prescription and medical supplies (close to the sector average annual deductible), but have not registered, and a second letter is sent as the member nears $1,700. They could refuse to provide coverage once the annual family maximum has been reached until the member registers for Fair PharmaCare.

23. Other Resources: Pacific Blue Cross: Has information sheets posted on:
Has information sheets posted on:
Coordination of Benefits
Direct Deposit and eStatements How-To Guide
PharmaCare and your Blue Cross Drug Plan
Online Self Service
Ways to Save Costs
10 things to ask your pharmacist
Prevent Fraud
10 things to ask your doctor
Employee Family Assistance Program
Brand name drugs vs Generics
Second Opinion
Understanding prescription drug prices
Disease Management Support Programs
Low-cost alternative drug pricing
Health and Wellness
Pharmacy Compass
Heath Protection Plus
Link to "Frequently Asked Questions" that provides brief information on multiple topics
Pay Direct Drugs
Blue Advantage Savings Program
Pacific Blue Cross has information sheets and other resources on their website that are accessible by the public.
Manulife Financial, HBT and CSBT do not have specific information accessible to the general public on their websites.

24. Pacific Blue Cross: Pharmacy Compass http://www.pharmacycompass.ca/
This site provides a cost comparison for pharmacies in your area and is accessible to the general public.
One of the PBC tools is what they call "Pharmacy Compass". If you click on "I Agree" you are redirected to a page with a search engine.

25. Pharmacy Compass, continued
A map showing the locations of the identified pharmacies is also provided below the summary.
You enter in the drug name, strength and a location. In this example we used the drug "Imipramine" and used our HQ address. The list that came up shows which pharmacies have filled a prescription for this drug in the past year and the costs associated with the purchase - as well as the dispensing fee charged by each. A map showing the locations also pops up below the table.

26. To Contact BC Pharmacare:
Vancouver:
From the rest of BC: toll free:
Monday to Friday, 8:00 a.m. to 8:00 p.m.
Saturday 8:00 a.m. to 4:00 p.m.
(except Statutory holidays)
You can register for Fair PharmaCare 24 hours a day, 7 days a week if you meet the eligibility requirements for online registration.

27. For information related to the BC Fair PharmaCare Program go to:
An online calculator found at: can be used to estimate of your Fair PharmaCare plan deductibles by entering the information requested.