1. Introduction to the BC PharmaCare Program

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What is BC PharmaCare?

PharmaCare is British Columbia’s prescription drug program that helps B.C. residents pay for:

• Eligible prescription drugs
• Eligible fees charged by pharmacy providers including
  • dispensing fees
  • clinical services fees (for renewal or adaptation of a prescription by a pharmacist)
  • medication management fees (for specific medication services)
  • fees for administering drugs and publicly funded vaccines
• Insulin pumps for people with insulin-dependent diabetes
• Continuous and flash glucose monitors and blood glucose test strips
• Specific insulin pump supplies
• Prosthetic devices (including mastectomy supplies)
• Orthotic devices for children 18 years or younger
• Ostomy supplies
• Certain over-the-counter and prescription smoking cessation products

When a person is considered a B.C. resident for PharmaCare purposes

A person is considered a B.C. resident and eligible for PharmaCare coverage if they meet the residency requirement for the Medical Services Plan (MSP).

>> Learn more about the MSP residency requirement.

Coverage for travel supplies

B.C. residents are eligible for an early “top-up” refill under the Travel Supply Policy once every 6 months (180 days). 

>> Learn more in Section 5.4—Travel Supply Policy.

Out-of-province coverage

PharmaCare does not cover eligible benefits for patients who are temporarily out of the province, except:

• Claims meeting requirements under the Section 5.4—Travel Supply Policy
• Claims from patients covered under the Plan W funding arrangement with the First Nations Health Authority (FNHA), under which out-of-province purchases of Plan W benefits may be reimbursed if the client submits a manual claim to PharmaCare
• Certain pre-approved out-of-province expenses when an individual requires treatment not available in B.C.

For example, PharmaCare covers eligible benefit medications and supplies for patients undergoing transplant procedures out of province (provided that PharmaCare receives faxed notification of the surgery from the BC Transplant Society).

In these cases, coverage of out-of-province medications and supplies remains subject to PharmaCare pricing policies and the usual rules of the patient's PharmaCare plan.

Any request for reimbursement for out-of-province purchases should be made in writing and include supporting documents to Health Insurance BC (HIBC).

Who is responsible for BC PharmaCare

The Pharmaceutical, Laboratory and Blood Services Division (PLBSD) of the BC Ministry of Health is responsible for the PharmaCare program and sets all policies governing the program.

Health Insurance BC (HIBC) administers the PharmaCare program on behalf of the Ministry and PLBSD. HIBC can answer questions about both the Medical Services Plan and PharmaCare.

How PharmaCare works

PharmaCare offers coverage through 12 plans:

• Fair PharmaCare plan (Plan I)—Income-based coverage for all B.C. residents
• Plan B (Long-term Care)—Permanent residents of licensed long-term care facilities
• Plan C (Income Assistance)—Recipients of B.C. income assistance or in care or a care agreement
• Plan D (Cystic Fibrosis)—Individuals registered with one of four provincial cystic fibrosis clinics
• Plan F (Children in the At Home Program)—Children eligible for benefits through the government's At Home Program
• Plan G (Psychiatric Medications)—For B.C. residents with clinical or financial need
• Plan P (Palliative Care)—Part of the BC Palliative Care Benefits program
• Plan W (First Nations Health Benefits)—For people enrolled with the First Nations Health Authority
• Plan M (Medication Management)—Clinical services provided by pharmacies for B.C residents
• Plan S (Smoking Cessation)—Smoking cessation products for any B.C. resident
• Plan X (BC Centre for Excellence in HIV/AIDS)—Antiretroviral medications 
• Plan Z (Assurance)—100% coverage for all B.C. residents

B.C. residents can be covered under more than one PharmaCare plan. For instance, a B.C. resident with cystic fibrosis may be covered under Fair PharmaCare for most of their eligible prescription and medical supply costs while they also receive coverage under Plan D for digestive enzymes and nutritional supplements.

Drugs and medical supplies does PharmaCare covers

PharmaCare covers a broad range of prescription drugs. For eligible patients, it also covers certain medical devices and supplies, prosthetics, orthotics, and non-prescription medications.

The drugs PharmaCare covers include eligible medications (as determined by PharmaCare) prescribed by a physician, dentist, midwife, nurse practitioner, naturopath, podiatrist, or optometrist licensed and practicing in B.C.
Smoking cessation products—specific nicotine replacement therapy products are fully covered for all B.C. residents with active MSP coverage.

>> Check the PharmaCare Formulary Search for information on the medications that PharmaCare covers.

More about medical supply coverage

PharmaCare covers the following medical supplies for the patients identified below:

• Insulin, needles, syringes, continuous/flash glucose monitors and blood glucose test strips and specific pump supplies—for adults and children with insulin-dependent diabetes
• Insulin pumps and specific pump supplies—for people with insulin-dependent diabetes
• Prosthetic devices (including mastectomy supplies)—for patients of any age
• Orthotic devices—for patients age 18 or younger
• Ostomy supplies—for ostomy patients of any age

>> Learn more about medical devices and supplies coverage.

Limits on what PharmaCare will cover

To ensure the PharmaCare program is financially sustainable, PharmaCare does not cover all prescription drugs. Instead, it covers drugs based on their effectiveness and cost.

PharmaCare fully covers some drugs (subject to the rules of a patient's PharmaCare plan) but only partially covers other drugs.

For instance, if several versions of a drug contain the same medically active ingredients, PharmaCare may cover only the lower cost versions. If several different drugs can be used to treat the same condition, PharmaCare may cover the more expensive drugs only if the patient has not been helped by the lower cost standard treatment.

Coverage may also be limited by the rules of a patient's PharmaCare plan.

For instance, under the Fair PharmaCare plan, if a patient and their spouse has annual net income above $30,000, they will have to meet a deductible (that is, pay their own drug costs and fees until the deductible is met). Once it is met, PharmaCare covers 70% of their eligible costs and fees for the rest of the year or until the family maximum is met. If the family maximum is met, PharmaCare pays 100% of eligible costs for the rest of the year. 

Items PharmaCare does not cover

There are items that are not part of the PharmaCare program. In some cases, PharmaCare has decided not to include an item as a benefit, or coverage may already be provided through another agency. In other cases, the manufacturer has not applied to PharmaCare to request coverage of their product.

>> Learn more about what is not covered by PharmaCare.

PharmaCare covers benefits only if they are dispensed by providers enrolled in the PharmaCare program.

How claims are processed

Most claims for prescription drugs and most medical supplies are submitted by a pharmacy or device provider on the provincewide computer network called PharmaNet.

Claims are automatically adjudicated on PharmaNet and the amount PharmaCare pays is deducted from the amount a patient pays when they pick up their product. Patients do not have to submit receipts to PharmaCare.

Any amount PharmaCare is contributing is printed on the pharmacy receipt.

PharmaNet adjudicates both product cost and pharmacy fees.

Pharmacy claims for services to long-term care facilities (capitation fees) and certain medical supplies must be submitted manually.

BC PharmaCare and Medical Services Plan (MSP)

MSP and PharmaCare are separate programs within the Ministry of Health.

MSP insures medically required services provided by physicians and supplementary health care practitioners, laboratory services and diagnostic procedures. PharmaCare covers eligible prescription drugs, some medical devices and supplies, and pharmacy services.

Other insurers

PharmaCare does not normally cover costs that are fully reimbursed by another payer.

>> For more information, refer to Section 3.4 Patients—Other Payers.