Help Your Employees Benefit From PharmaCare

Each of the provinces across Canada have set up a publicly funded program that helps residents with their health care. In Ontario it’s the Ontario Health Insurance Plan (OHIP), in Quebec it’s the Régie de l'assurance maladie du Québec (RAMQ), and in BC we call it PharmaCare.

All BC residents are eligible for PharmaCare (new residents have a 3-month waiting period), and every resident of BC should register and take advantage of the benefits this plan has to offer. If your employees—especially those with chronic conditions—are concerned about the cost of their prescription drugs or other supplies, have a conversation with them about PharmaCare. Employees who haven’t registered can do so on the GovBC website.

PharmaCare covers eligible prescription drugs and dispensing fees, some medical devices, and some pharmacy services. We’ll explain how it works and some items that are covered.

Prescription Drugs

PharmaCare has a net income test for prescription drugs and medical supply coverage that will determine a family’s deductible and maximum. However, PharmaCare also ensures that BC residents, regardless of income, are protected from catastrophic drug costs.

Deductibles and Maximums

PharmaCare has a deductible: The amount the family needs to spend each year before PharmaCare will start to help with the cost. Once the deductible is reached, PharmaCare pays 70% of costs (75% for families with a member born before 1940).

PharmaCare also has a maximum. This amount is the most employees must spend out of pocket, per year, before PharmaCare will pay 100% of the eligible expense for the rest of the year.

For example, if an employee's net income is $60,000 per year and their spouse's net income is $40,000—for a combined household maximum of $100,000—then PharmaCare would begin covering 70% of the family’s eligible prescription drug costs once the family has incurred $3000 in a calendar year. Furthermore, when the family’s eligible drug costs reach $4000, PharmaCare will cover 100% of the eligible costs for the balance of the year.  The deductible and maximum would be the same for a single employee with a net income of $100,000 per year.

The deductible and maximum reset every Jan 1st. The deductible and maximum can be calculated using this handy calculator.

Any Canadian group plan with employees residing in BC will integrate with PharmaCare. Insurance carriers often ask for an employee’s PharmaCare deductible and maximum to ensure that errors such as double payment are not made.

Controlling Costs

PharmaCare sets a maximum price it will recognize for each drug in the provincial formulary.  The formulary is a list of prescription drugs which PharmaCare covers. It is important to note that not all prescription drugs in the marketplace are covered under provincial formularies. The pipeline for provincial approval is a long one, and the efficacy vs. cost of a drug, relative to other drugs for the same condition already in the marketplace, is considered.

In addition to maximums on drugs, the province also sets a maximum reimbursement level for dispensing fees. If the drug cost or dispensing fee at your employee’s pharmacy exceeds this maximum price, employees must pay the additional cost. 

The cost covered by PharmaCare is calculated at the time of purchase at the pharmacy. PharmaCare’s Low Cost Alternative (LCA) program helps control the cost of prescription drugs. When the same drug is made and sold by more than one manufacturer, PharmaCare covers the less costly version—the LCA.

Every prescription dispensed in any BC community pharmacy is recorded in PharmaNet, and the information can be used by pharmacies, hospitals, and emergency departments to improve drug safety and provide accurate treatments. 

Medical Devices and Supplies coverage

PharmaCare also covers medical devices and supplies. Some examples of devices and supplies covered by PharmaCare are:

• Prosthesis for limb, breast, ocular, nasal and ear prostheses needed to attain or maintain basic functionality.
• Custom Orthoses for patients aged 18 or younger that are needed to attain or maintain basic functionality or to prevent future deformity. This includes plagiocephaly helmets for infants.
• Ostomy Supplies for people who have undergone bowel or bladder surgery that results in a colostomy, ileostomy, or urostomy, requiring an external pouch.
• Diabetes Management Supplies including insulin pumps and supplies, blood glucose test strips, insulin, needles and syringes for diabetics who inject insulin.

The BC government makes changes to coverage levels and approved items regularly.. So it’s important employees check with PharmaCare for any medical devices and supplies they may need.

Summary

PharmaCare helps BC residents to ensure their family is protected from catastrophic drug costs, and reduces pressure on employer sponsored plans for most medications. This protection comes with some additional benefits to help with the cost of medical devices and supplies. For employees with chronic conditions or who face an unexpected health crisis, the benefits of PharmaCare along with other aspects of your company's healthcare plan are there to ease financial worry.