Top Q&As from health benefits changes webinar
The board has committed to posting the top enquiries it received from its health benefits webinar.
Below is a set of common questions and answers from the health benefits changes webinar, which have been edited for clarity, brevity and relevancy. The board encourages you to learn more. You may wish to start by reviewing the information and details under Changes to retirement group health benefits.
What is the lifetime maximum limit?
The limit is $250,000 per person. This was increased from $200,000 in 2019. After you reach this limit, Green Shield Canada (GSC) stops paying claims. However, PharmaCare will continue to pay for drugs and medical supplies eligible under its program. By using drugs covered by PharmaCare, you will accumulate costs more slowly toward your lifetime maximum because the health benefits program will bear fewer costs.
What does “co-insurance” mean?
Co-insurance refers to the level of reimbursement the benefits program covers. Until December 31, 2021, the co-insurance amount for your health benefits is 70 per cent for extended health care coverage.
What does “paid claims” mean? Is that the total cost of drugs or only the portion paid as it applies to deductibles?
“Paid claims” is the total amount of extended health benefits paid by GSC on your behalf.
Are compounds covered?
Due to their complexity, compound drugs are covered under tier 1, even if it they are not eligible for coverage with PharmaCare. Generally, every carrier has its own rules for what compounds are eligible, and the Public Service Pension Plan will continue to follow GSC’s compound drug policy. Please familiarize yourself with the policy by following the link in External links.
Who decides which vaccines are covered?
The plan’s board of trustees makes this decision with input from plan members.
How does a secondary plan cover the remaining costs?
A secondary plan covers the portion of any remaining costs not covered by the primary plan. For example, a member’s non-PharmaCare drug is covered on tier 2 at 60 per cent. The remaining 40 per cent could be covered by a secondary plan, depending on the rules of the secondary plan. This is also referred to as “coordination of benefits.”
How do changes affect members who live outside BC?
If you live outside BC, there will be no changes to your drug coverage. The new design is built on the BC PharmaCare formulary, which does not pertain to plan members living outside the province.
Will there be any changes to the six-month vacation supply provision that is currently available?
No, there will be no changes to the six-month vacation supply provision. Existing provisions and exceptions will still remain under the plan.
Can you explain the dispensing fee?
The health benefits program covers dispensing fees up to a maximum of $10. If your prescription is a PharmaCare-eligible prescription, it will cover 80 per cent of the dispensing fee, up to that maximum (i.e., $8). If the prescription is not PharmaCare eligible, it will cover 60 per cent of the maximum (i.e., $6). Your maximum dispensing fee is aligned with PharmaCare’s maximum dispensing fee of $10. If PharmaCare changes its maximum dispensing fee, your program’s maximum dispensing fee will also change to match.
Can you clarify “net income” when it comes to PharmaCare? What if I have a high income but costly medical expenses take up most of it?
Net income calculated on line 23600 of the federal income tax return does not include medical expenses. Medical expenses form part of the calculation of non-refundable tax credits in lines 30000 to 34900. If medical expenses are high enough, then they can help reduce the tax bill.
Is the net income for each member adjusted annually for the plan?
Yes. PharmaCare is authorized to access your net income when you file your annual income tax return. PharmaCare uses the net income filed on your tax return two years prior to the current year to calculate your deductible. If you anticipate your income for a year will be at least 10 per cent less than your income two years earlier, you can apply for an adjustment by filling out an Application for Income Review. Look under External links for a link to the form.
Who pays what amount when it comes to the deductibles?
PharmaCare bases each individual’s annual deductible on net family income. Net income equals the amount on line 23600 on your tax return, minus any amount reported on line 12500 (income from a Registered Disability Savings Plan). The PharmaCare deductible portion is paid by your benefits program through GSC.
Your benefits program has an annual deductible of $250, which is not related to the PharmaCare deductible. The $250 deductible is the out-of-pocket amount you must pay in each calendar year before the plan starts paying for extended health benefits.
What is the PharmaCare deductible based on?
PharmaCare bases each individual’s annual deductible on your net family income from two years earlier. Net income equals the amount on Line 23600 on your tax return, minus any amount reported on Line 12500 (income from a Registered Disability Savings Plan). See How Your Coverage is Calculated under External links.
Is there a list available to check if a drug is on the PharmaCare formulary?
Since there are over 4,000 drugs on the BC PharmaCare formulary, we suggest you use PharmaCare’s formulary search tool. You can find a link to the tool in External links. The search tool will tell you which drugs are covered by PharmaCare. The tool will not display whether your drug is tier 1 or tier 2. It’s important to note:
- Tier 1 drugs, which have 80 per cent coverage, are covered by BC PharmaCare.
- Tier 2 drugs, which have 60 per cent coverage, are not covered by BC PharmaCare.
- If your drug is not listed or it displays “$0.00” or shows no value under the Maximum PharmaCare Covers column, then it is not covered by PharmaCare. Therefore, it would be considered a tier 2 drug.
- Click on the highlighted DIN/PIN/NPN number to show details for the product. The result may indicate the drug as a “non-benefit,” which means it is a non-PharmaCare drug and would be covered under tier 2.
Our family didn’t apply for PharmaCare because our household income was too high. Should we apply now?
We encourage all members to apply to PharmaCare. If you do not apply to Fair PharmaCare, your default annual deductible is $10,000. If you need an expensive drug in the future and your income decreases, PharmaCare would automatically lower your personal PharmaCare deductible.
Do tier 2 drugs count toward the PharmaCare deductible level?
No. Only tier 1 drugs that are eligible with BC PharmaCare count toward the PharmaCare deductible.
How will I know if my special authority request was approved?
When the pharmacy fills your prescription, it will confirm your special authority approval from PharmaCare. The pharmacy will send the approval to GSC, and the correct reimbursement level will be applied. If there is a delay, you can call PharmaCare to ask about the status of your special authority request. If the pharmacist confirms you have special authority approval and your coverage is lower than expected, please call GSC for assistance. There are some pharmacies in BC that are not able to send your special authority approval electronically to GSC.
What if I already have special authority approval with PharmaCare. What will my reimbursement be?
If you currently have special authority approval with PharmaCare for a particular drug, there should be no disruption, and the information will automatically be sent to GSC when your pharmacy fills your prescription. You would have tier 1 coverage at 80 per cent.
How do I know if my family is covered by PharmaCare? Does registration happen automatically?
You are not automatically registered for PharmaCare. You can register through a simple process on BC PharmaCare’s Fair PharmaCare website. You only need to register once.
You can confirm your PharmaCare registration status by visiting the Fair PharmaCare registration status search website.
You just need to provide your personal health number, birthdate and mailing postal code to confirm the status of your registration or call 1-800-663-7100 or 604-683-7151 (in the Lower Mainland).
Am I eligible for PharmaCare if I haven’t completed my current tax return?
To maintain your Fair PharmaCare coverage, you must file a tax return every year.
For more information on Fair PharmaCare, call 1-800-663-7100 or 604-683-7151 (in the Lower Mainland).
About the changes
Until December 31, 2021, the health benefits program provides 80 per cent coverage for drugs from discount pharmacies like Costco. Will there be a similar discount offered with the new benefits program?
The new benefits program doesn’t offer Costco-preferred pricing. Changes mean all members will be covered at 80 per cent for tier 1 drugs.
I use a non-PharmaCare drug because I couldn’t tolerate the PharmaCare-approved options. Will I be covered on tier 2 at 80 per cent?
If you’re taking a non-PharmaCare drug and have a medical reason to remain on it, you may be eligible for full coverage. Your doctor may request special authority coverage through PharmaCare for your non-PharmaCare drug. Once PharmaCare approves the exceptional coverage, the approval will automatically be sent to GSC and you should get full coverage for your non-PharmaCare drug.
Are changes being made to the health benefits program because of the pandemic?
No. The board started its review long before the pandemic arrived. The board reviews the program’s health benefits periodically to ensure the offered benefits and available funding are managed effectively. The board’s goal is to ensure health benefits remain valuable and sustainable for the long term.
Is there a strategy for when national PharmaCare is implemented? What would be the impact on the health benefits program?
It’s unlikely a national PharmaCare program will fully replace a private health benefits plan anytime soon. If circumstances change, the board will examine the program and available funding in anticipation of any new developments.
What would be the impact on the cost of drugs based on the Patented Medicine Prices Review Board?
The role of the Patented Medicine Prices Review Board (PMPRB) is to ensure that the prices of patented drugs sold in Canada are not excessive. New PMPRB guidelines have been established to help set lower prices of new patented drugs. The new regulations come into effect on January 1, 2022. However, there may be further delays as they are being challenged in court.
Will premiums for extended health care remain the same?
For members who pay premiums, rates are adjusted annually. The board regularly reviews health benefits funding to ensure it is sufficient to cover future needs. Coverage can change at any time, and your premiums, subsidies and deductibles could increase, decrease or be eliminated.
Premiums for 2022 will be available online and in the winter edition of Pension Life. Premiums are usually effective February 1 and paid one month in advance (new premiums will be deducted from January pension payments).
The pension plan subsidizes the cost of monthly premiums for extended health care based on your years of pensionable service. The subsidy is not guaranteed. The plan does not subsidize the cost of monthly premiums for your spouse and dependants.
The plan also does not subsidize the cost of the dental program’s monthly premiums.
Drug identification number (DIN)
Is it mandatory for the DIN to be on the label of every prescription?
A drug identification number (DIN) is assigned by Health Canada to every commercially manufactured drug product once it has been evaluated and authorized for sale in Canada. It is required by law for the DIN to be on drug labels.
Is a drug without a DIN covered?
Commercially manufactured drugs without DINs are generally not covered. There are some drug and medical products covered under your plan that do not have an official DIN, such as compounds and diabetic supplies.
Who sees information about household income?
After you register for Fair PharmaCare, BC PharmaCare has access to household income information through submitted income tax returns. Neither the board nor GSC have access to information about your household income.
Related content for top Q&As from health benefits changes webinar
Modified drug plan with a tiered formulary
External links for top Q&As from health benefits changes webinar
Fair PharmaCare plan application for income review
Fair PharmaCare registration status search
Green Shield Canada benefits booklet
Green Shield Canada compound drug policy
How your coverage is calculated