Pharmacare Tie-In

What Does it

Really Mean?

Changes to the Extended Health Drug Coveragefor Groups Moving to a PharmaCare Tie-In

No ImpactIf your drug is included on the BC Pharmacare formulary you will not see a difference in the coverage under your extended health plan.

No ImpactIf your drug is included on the BC Pharmacare formulary you will not see a difference in the coverage under your extended health plan.

To find out if a drug is on the Pharmacare formulary:To find out if a drug is on the Pharmacare formulary:www.health.gov.bc.ca/pharmacare/benefitslookup

A search for "Tecta" brings up pantoprazole magnesium.

When you click on the drug name you get the summary below:

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 604-683-7151 or 1-800-663-7100

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 604-683-7151 or 1-800-663-7100

The Ministry of Health Website:http://www.health.gov.bc.ca/pharmacare/sa/criteria/genericbrandtable.html

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: TectaGeneric Drug: pantoprazole magnesium

How to Access the BC Pharmacare Special Authority Program:STEP 1:

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:

http://www.health.gov.bc.ca/pharmacare/or

Call 604-683-7151 or 1-800-663-7100 (toll free)

Monday - Friday 8:00 a.m. to 8:00 p.m. and Saturday 8:00 a.m. - 4:00 p.m.

Step 2: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 physicianand are available online at:

www.health.gov.bc.ca/pharmacare

Your doctor will fax the completed request to thenumber shown on the form.

Step 3: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.

Special Authority Process OverviewSpecial Authority Process Overview

Physician, dentist or hospital pharmacist

submits Special Authority request to PharmaCare

By fax to 1-800-609-4884

Monday to Friday 8 a.m. to 8 p.m.

PharmaCare assigns a priority level to the request

URGENTURGENT PRIORITYPRIORITY REGULARREGULAR

Decision within one business dayDecision within

one business day

Decision within two business

days

Decision within two business

days

Decision within 10 business daysDecision within

10 business days

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

Decision communicated to applicant by fax/mail

APPROVED DENIEDNOT APPROVED - more info required

If your drug is not included on the BC Pharmacare Formulary: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:Some common drugs that are not covered:

Low Cost Alternative (LCA) and Reference Based Drug (RDP) Programs: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:

http://www.health.gov.bc.ca/pharmacare/lca/lcabooklets.html

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.

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.

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.

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.

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).

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.

Fair Pharmacare: How does it fit in?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)

• 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 $1,200.00. • 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.

When you reach your Fair PharmaCare Annual Family Deductible:When you reach your Fair PharmaCare Annual Family Deductible:

When you reach your Fair PharmaCare Annual Family Maximum:When you reach your Fair PharmaCare Annual Family Maximum:

Annual Family Maximum:

•Our example family will have an annual family maximum of $1,600.00.

•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.

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 $0.00 70% $25.00

$1,875.01 $3,125.00 $0.00 70% $50.00$3,125.01 $4,375.00 $0.00 70% $75.00$4,375.01 $6,250.00 $0.00 70% $100.00$6,250.01 $8,750.00 $0.00 70% $150.00$8,750.01 $11,250.00 $0.00 70% $200.00

$11,250.01 $13,750.00 $0.00 70% $250.00$13,750.01 $15,000.00 $0.00 70% $300.00$15,000.01 $16,250.00 $300.00 70% $450.00$16,250.01 $18,750.00 $350.00 70% $525.00$18,750.01 $21,250.00 $400.00 70% $600.00$21,250.01 $23,750.00 $450.00 70% $675.00$23,750.01 $26,250.00 $500.00 70% $750.00$26,250.01 $28,750.00 $550.00 70% $825.00$28,750.01 $30,000.00 $600.00 70% $900.00$30,000.01 $31,667.00 $900.00 70% $1,200.00$31,667.01 $35,000.00 $1,000.00 70% $1,350.00$35,000.01 $38,333.00 $1,100.00 70% $1,475.00$38,333.01 $41,667.00 $1,200.00 70% $1,600.00$41,667.01 $45,000.00 $1,300.00 70% $1,750.00$45,000.01 $48,333.00 $1,400.00 70% $1,875.00$48,333.01 $51,667.00 $1,500.00 70% $2,000.00$51,667.01 $55,000.00 $1,600.00 70% $2,150.00$55,000.01 $58,333.00 $1,700.00 70% $2,275.00

PDF file showing Annual Deductibles by Net Income can be found at:

http://www.health.gov.bc.ca/pharmacare/plani/calculator/pdf/income_bands_fair_pcare_regular.pdf

PDF file showing Annual Deductibles by Net Income can be found at:

http://www.health.gov.bc.ca/pharmacare/plani/calculator/pdf/income_bands_fair_pcare_regular.pdf

If you have not filed income tax returns or are not registered for Fair PharmaCare your annual family deductible is $10,000.00

only after you have met this deductible will PharmaCare will pay 100% of the eligible costs.

If you have not filed income tax returns or are not registered for Fair PharmaCare your annual family deductible is $10,000.00

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 70% $2,550.00$65,000.01 $70,833.00 $2,000.00 70% $2,675.00$70,833.01 $79,167.00 $2,250.00 70% $3,000.00$79,167.01 $87,500.00 $2,500.00 70% $3,350.00$87,500.01 $95,833.00 $2,750.00 70% $3,675.00$95,833.01 $108,333.00 $3,000.00 70% $4,000.00

$108,333.01 $125,000.00 $3,500.00 70% $4,675.00$125,000.01 $141,667.00 $4,000.00 70% $5,350.00$141,667.01 $158,333.00 $4,500.00 70% $6,000.00$158,333.01 $183,333.00 $5,000.00 70% $6,675.00$183,333.01 $216,667.00 $6,000.00 70% $8,000.00$216,667.01 $250,000.00 $7,000.00 70% $9,350.00$250,000.01 $283,333.00 $8,000.00 70% $10,000.00$283,333.01 $316,667.00 $9,000.00 70% $10,000.00$316,667.01 $999,999,999.00 $10,000.00 100% $10,000.00

Deductible for a family registered for Fair PharmaCare whose income cannot be verified $10,000.00 100%

Deductible for a person actively enrolled in the Medical Services Plan but not registered for Fair PharmaCare $10,000.00 100%

Other Resources:Other Resources:Pacific Blue Cross:

http://www.pac.bluecross.ca/Corp/howbenefitswork/getthemost/

Has information sheets posted on:

Pacific Blue Cross:Pharmacy Compasshttp://www.pharmacycompass.ca/

Pacific Blue Cross:Pharmacy Compasshttp://www.pharmacycompass.ca/

This site provides a cost comparison for pharmacies in your area and is accessible to the general public.

A map showing the locations of the identified pharmacies is also provided below the summary.

Pharmacy Compass, continuedPharmacy Compass, continued

To Contact BC Pharmacare:To Contact BC Pharmacare:

Vancouver: 604-683-7151From the rest of BC: toll free: 1-800-663-7100

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.

Fair Pharmacare:Fair Pharmacare:

For information related to the BC Fair PharmaCare Program go to:

http://www.health.gov.bc.ca/pharmacare/fpcreg.html

An online calculator found at:

http://www.health.gov.bc.ca/pharmacare/plani/calculator/calculator.html

can be used to estimate of your Fair PharmaCare plan deductibles by entering the information requested.