On June 1st, 2013, the changes to our prescription drug coverage came into effect. These changes are referred to as the “Pharmacare Tie-In”, which basically means we are now enrolled in the governments Pharmacare program. Since its implementation, many members have raised questions or concerns with the new coverage.
The Pharmacare program is formulary based prescription coverage plan, which was developed by the provincial government several years ago. This plan uses a medical review panel to determine coverage eligibility for prescription medication on an individual basis. With the goal of cost control, preference is always given to the ‘generic’ medication, rather than the name brand, which achieves the same therapeutic action. Each medication is evaluated by the Pharmacare review panel, then assigned one of three levels of coverage in the program:
- Covered – Means the medication is covered (may have per pill / dose limits).
- Special Authority – Means the medication is covered once the patient obtains and submits a completed ‘Special Authority’ form (may have per pill / dose limits).
- Non-benefit – Means the medication is not covered, either because it has a generic equivalent, it has been ruled to have no proven therapeutic value or it has not yet been evaluated.
Pacific Blue Cross administers our prescription medication coverage, using the Pharmacare Formulary as the determinant. Neither Pacific Blue Cross, the Employer or the Union have a voice in determining what category of coverage is assigned to a particular medication. That role lies solely with the Pharamacare review panel, which is comprised of physicians and other industry professionals.
With this change of coverage, it is important that members discuss with both their physicians and pharmacists about which medications they are being prescribed. Members should always ask if the medication being prescribed is eligible for coverage under the BC Fair Pharmacare Formulary. In BC, both your physician and your pharmacist have the ability to “swap” a non-covered prescribed medication for a covered version. Members can also easily look-up any particular medication themselves, on the Pharmacare website.
Obtaining ‘Special Authority’ – If a prescribed medication is listed as requiring a ‘Special Authority’ form, then the member must submit this completed form to obtain coverage. The form can be
downloaded from the Pharmacare website, then presented to the prescribing physician.
Any fees incurred to obtain a completed special authority form are covered, and should be submitted to PBC.
Some physicians may be reluctant to complete the form, or want to charge a ‘fee’ to do so. As the patient, members must be their own advocate in ensuring the form is completed. Without it, Pacific Blue Cross will not reimburse medications within this category. If a fee is charged to complete the form, members are advised to submit that expense to Pacific Blue Cross for reimbursement.
Provided below are some useful links for members to manage their coverage:
- BC Pharacare Medication Lookup: Go here to search for any medication to see if its covered, requires a special authority or is a
- Special Authority Form: If a medication requires special authority for coverage, then this is the form they need
completed. Read here about how to submit the completed form.
- Blue Cross FAQ for FBA members: General questions and answers specific to FBA employees (that’s us).
- Blue Cross Pharmacy Compass – Find the best price for your medication, in your area.
Issues & Problems – Since implementation, some issues and problems have been identified, which require grievance action to resolve.
- Special Authority Processing Delays – During negotiations, the employer group committed that processing times for special authority forms would be 6 to 10 days. Apparently they did not take into account the over
100 thousand new plan participants, therefore drastically increasing the number of submissions. As a result, processing times are now currently 2 to 3 months.If members experience extended delays in processing, and these delays result in an increased cost to the member, they should file a grievance to achieve resolve.
UPDATE – July 2, 2014 – Policy Grievance Resolve
As you are aware, with the adoption of prescription medication coverage under the “Fair Pharmacare Program” in 2013, members have identified a number of issues with their coverage. These issues were in stark contrast to the obligations made by the Employer group during negotiations on this matter. As a result, CUPE Local 873 and all other Unions included in the Facilities Bargaining Association (FBA) filed and proceeded with Policy Grievance action against the Employer group.
Today, I am able to inform you that we have reached agreement on a resolve to the Policy Grievance. The full resolve is attached, however the highlights are:
- CUPE Local 873 members will receive retroactive coverage for a list of ten medications, which have been identified as “high use” within the membership.
- To be eligible for this coverage, members or their dependents must have been prescribed and claimed the particular medication in the period of December 1, 2012 and June 1, 2013.
- The ten medications are:
- Eligible members will continue to receive coverage for these medications indefinitely.
- All prescription medication coverage, including per-dose limits and dispensing fees, as detailed in the Fair Pharmacare Program will be in effect.
- Within 90 days, Pacific Blue Cross must contact all eligible members to inform them of their eligibility and inform them of the process to claim retro-active reimbursement.
- Continued coverage for those members on Long Term Disability.
- Pacific Blue Cross will develop a new process to assist Unions and members with the identification of exactly what medications are, or are not, covered.
- Within 90 days, the parties will establish a joint review process, with the authority to investigate and resolve member coverage disputes.
- Establishes coverage for physician fees related to completion of special authority fees.
This agreement means that prescription coverage is available to all existing APBC members who receive medical benefits, for the entire list of top-50 medications claimed by the APBC membership. This coverage will be in effect starting September 15, 2014.
In addition, effective July 1, 2014, APBC members can now apply their prescription medication coverage immediately at the pharmacy counter. Simply inform the pharmacist that you are eligible for Pacific Blue Cross direct-pay. This will ensure that members are aware of exactly what medications are, or are not, covered, prior to purchasing.
If you have any further questions about the change in prescription medication coverage, please contact your RVP for assistance.