Top Q&As from health benefits webinar
The board has committed to posting the top enquiries it received from its health benefits webinars held on November 2 and 12. Below are the questions and responses, which have been edited for clarity and brevity.
The board encourages you to learn more. You may wish to start by reviewing the information and details about the engagement and proposed changes.
Scope of proposed changes: What would change? What stays the same?
Are changes being considered to just the drug plan?
Yes. Generally, the board has observed that prescription drug costs are increasing. Members are also taking more medications, and most new drugs coming to market are more costly than current drugs that treat the same condition.
The pension plan’s demographics are also changing as more members transition into retirement. With more retired members and the rising costs of prescription drugs, the board anticipates it will cost more in the future for the plan to provide extended health care subsidies.
Would the deductible remain the same?
Yes, it would remain at $250. Once you reach your deductible, your prescription drugs would be covered at the co-insurance level set for Tier 1 until total claims reach $2,000. Then you would receive 100 per cent reimbursement for Tier 1 drugs (i.e., not Tier 2 drugs).
Would there be changes to premiums?
No. Premiums will remain the same for extended health care and dental; however, the board reviews them annually and they may change slightly from year to year.
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 and can be changed or eliminated at any time. The plan does not subsidize the cost of monthly premiums for your spouse and/or dependants.
The plan also does not subsidize the cost of the dental program’s monthly premiums.
What is the current 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 stops paying claims; however, PharmaCare will continue to pay. The proposed changes to your drug plan would give you more room under your lifetime maximum for other benefits. By using the drugs listed on the PharmaCare formulary, you will pay less out of pocket and have lower amounts accumulating toward your lifetime maximum of $250,000.
What about coverage for compounded drugs?
Due to their complexity, compound drugs would be covered under Tier 1, even if they are not eligible for coverage with PharmaCare. Generally, every carrier has its own rules for what compounds are eligible, and the pension plan will continue to follow Green Shield’s compound drug policy. Please familiarize yourself with the policy.
Why is funding of health benefit subsidies limited to employer contributions of one per cent of current payroll?
The one per cent is a maximum set by the plan partners and will remain the same. This percentage is a financial constraint for the board, who seeks to maintain the long-term sustainability and value of the health benefits program. The one per cent is contributed by all employers in the plan. It’s important to note that neither member contributions nor investments can be used for retirement group health benefit subsidies.
The federal government has discussed a national pharmacare program. How would that affect the plan’s health benefits program?
The federal government announced it’s on the path to developing a nationwide program. One objective is to lower costs for Canadians. Based on the board’s understanding of the proposal, this is a massive undertaking. If a national pharmacare program is realized, members could begin to shift away from private plans. The board continues to monitor the discussions about a national program.
The Municipal Pension Plan (MPP) has proposed setting up a health benefit trust to add more flexibility in funding for its retiree group health benefits. Is this something the Public Service Pension Plan (PSPP) might consider?
The board did consider a health benefits trust by assessing input from an independent consultant and reviewing advantages and disadvantages. The board decided to not pursue a trust but will monitor the situation with MPP’s proposed plan changes and learn how its approach may work for PSPP.
While the board is not in a position to speak on behalf of MPP, it can address its own pension plan’s health benefits funds.
Funds for the health benefits program continue to grow; however, the board is noticing important changes that are affecting growth of the funds.
The board has three proposed options outlined in the webinar recording—all options will improve the long-term financial sustainability of health benefits. The options are intended to free up funds, which would allow for the possibility to enhance other health benefits or lower premiums in the future.
Watch the board’s video under Learn about the engagement process to learn more about health benefits funding.
The cost of proposed changes
Is there a cost for each of the three options?
The costs are relatively equal for each of the three options. Each option was designed to offer a trade-off. The higher co-insurance options have shorter grandparenting periods, while the longer grandparenting periods have lower co-insurance levels.
Is there a fourth option?
No additional options will be considered. The options presented are the result of comprehensive data analysis and thorough consideration, and are based on the following guiding principles:
- Protect against catastrophic health expenses
- Maintain sustainability of the program
- Cover cost-effective drugs
- Leverage public drug programs
Maintaining the status quo isn’t an option with the rising cost of prescription drugs. The board has determined that changes are required to ensure the sustainability of the program. If changes are made sooner, the plan can afford to offer more choices, such as grandparenting.
Can you clarify the grandparenting periods?
If you’ve been taking a non-PharmaCare prescription drug that treats a chronic condition and had coverage for your drug by the plan 12 months prior to when changes are implemented, you would maintain your coverage at 70 per cent for an extended period of time. After the grandparenting period expires, you would be covered at the lower co-insurance level.
If you’re an active member and have not yet enrolled in the health benefits program, coverage for your non-PharmaCare drug would not be grandparented.
The cost of drugs
Why are new drugs so expensive?
There has been an increase in the number of new drugs available that treat specialized conditions, such as cancer and rare diseases. These targeted drugs are expensive to develop and produce. Drugs that cost between $10,000 and $25,000 per patient annually contribute to the most growth for private drug plans (based on a report by Innovative Medicines Canada).
Are pharmacies permitted to apply a mark-up?
Yes, pharmacies, like any retailer, are permitted to mark up their products; therefore, prices vary between pharmacies.
Costco pharmacy usually has the most competitive prices, and you don’t require a Costco membership to fill your prescriptions. London Drugs pharmacy and Save-On-Foods pharmacy tend to have lower prices than others.
How do I find out why my drug isn’t covered anymore?
There may be many reasons why you no longer have coverage for your drug. For example, each carrier has their own standard coverage rules, such as compound policies. We recommend you contact Green Shield and speak to a representative to enquire about your specific drug.
Brand and reference drugs versus generic and non-reference drugs
Can the pharmacist, not your doctor, switch your prescription from a brand to generic drug?
In BC, a pharmacist has the authority to make the switch from a brand to generic drug without a doctor’s approval. However, in some provinces the pharmacist can switch between the brand and generic only if the drug is on a provincial interchangeability list.
What about reference drugs? Can the pharmacist also switch my medication?
Pharmacists can assist patients by making a therapeutic substitution to the reference drug from a non-reference drug within the same therapeutic class. However, pharmacists do not often apply this practice and in most cases you will need to see your doctor to switch from a non-reference drug to a reference drug.
What if it’s difficult to see my doctor?
Many doctors offer phone and online appointments, making it easier for you to speak with your health professional. The board is aware of this challenge for members and has offered grandparenting periods in the proposed options to give you time to discuss the transition with your doctor. A pharmacist can also assist in some situations.
What if I’m on a medication that is working well? Or what if a generic or reference drug causes adverse reactions? Are you proposing that I take only a generic drug?
If you’re taking a brand or non-reference drug and have a medical reason for not taking the generic or reference drug, you may be eligible for full coverage of the brand or non-reference equivalent. Your doctor may request special authority coverage for your drug through PharmaCare. Once you have received documentation confirming special authority approval, you would forward it to Green Shield to get full coverage from the plan for the brand or non-reference drug.
What if a generic or non-reference drug is difficult to obtain because of COVID-19?
If your pharmacy and its wholesalers are short on supply for a generic or reference drug, it will notify PharmaCare. PharmaCare will provide full coverage of the brand or non-reference drug. You can then submit your receipt to Green Shield and provide an explanation. Green Shield will reimburse you for the brand or non-reference drug.
Do I need to register for PharmaCare?
You can register for PharmaCare at any age and life stage (e.g., before or after retirement). The board encourages all members to register. You can register through a simple process on the PharmaCare website.
How will I know if I’m already registered?
You can confirm your PharmaCare registration status by visiting PharmaCare’s status search website.
If a family has a net income of $50,000 and the PharmaCare deductible is three per cent, does this mean there’s no coverage through PharmaCare until spending on drugs reaches $1,500?
Yes, that’s correct. PharmaCare is income-based and will not cover your eligible prescriptions until you meet your deductible, which is about three per cent for most households but can vary slightly depending on your income. There is enhanced assistance for those born in or before 1939.
The pharmacy will coordinate your drug benefits (through Green Shield) with PharmaCare if your prescription is eligible with PharmaCare. After you meet the first deductible (about three per cent), PharmaCare starts paying 70 per cent of the eligible cost of your drugs and Green Shield pays the remaining 30 per cent. As you continue accumulating and reach the second deductible (about four per cent), PharmaCare pays 100 per cent of your eligible drug costs.
What is the relationship between PharmaCare and Green Shield? Am I paying two deductibles, one to Green Shield and one to PharmaCare?
You only pay one deductible to Green Shield. After you pay your health benefits program deductible, Green Shield will pay your PharmaCare deductible. Once you meet your PharmaCare deductible, drug costs for you and your family will shift from Green Shield to PharmaCare coverage, which will save you and the plan money.
What is a special authority and what role does it play in getting approval for a Tier 2 drug?
Special authority is approval by PharmaCare for members to take a more costly medication on their formulary. If you already have special authority on file, Green Shield will already have it in their system and you do not need to reapply.
How do I know if I am on a drug that needs special authority approval by PharmaCare?
Use PharmaCare’s formulary search tool. When your drug displays, it should indicate “Yes” under the “Special Authority Needed” column. You can also ask your doctor or pharmacist. Your doctor would apply to Pharmacare for special authority approval. Please note some specialists have automatic special authority.
If you currently have special authority for a particular drug, there will be no disruption, and the information will automatically be transmitted to Green Shield when your pharmacy fills your prescription and you would have Tier 1 coverage.
How do I use PharmaCare’s formulary search? How do we know if my drug is Tier 1 or Tier 2?
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 would be drugs covered by BC PharmaCare
- Tier 2 would be drugs not covered by BC PharmaCare
- If your drug is not listed or it displays but there is $0.00 or no value under the “Maximum PharmaCare Covers” column, then it is not covered by PharmaCare. Therefore, it’s considered a Tier 2 drug.
- Click on the 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.
For reimbursement, do I need to submit claims to PharmaCare?
No, you do not need to submit claims to PharmaCare. If you give the pharmacy your Green Shield pay direct card and personal health care number, claims are processed at the pharmacy. Every pharmacy in BC sends claims to PharmaCare first and then to your health carrier. For more costly drugs requiring special authority approval, if you have PharmaCare approval, it will be automatically sent to Green Shield and would be covered under Tier 1.
Is there a lifetime maximum for PharmaCare?
There is no lifetime maximum under PharmaCare.
If I live outside of BC, how would the proposed tiered formulary affect me (i.e., would BCPharmaCare still apply)?
For members living outside of BC, the redesigned drug plan would still apply different levels of reimbursement that would follow the BC PharmaCare formulary (most provincial formularies are relatively similar).
Having a tiered formulary would mean that certain drug types would be grouped into tiers, and each tier would be reimbursed at a different amount. The board proposes to base its tiers on BC PharmaCare coverage:
- Tier 1 would be drugs covered by BC PharmaCare
- Tier 2 would be drugs not covered by BC PharmaCare
The main difference is if you live outside of BC and require special authority coverage for high-cost drugs (drugs that require prior authorization), you would require approval by Green Shield (as opposed to requiring approval by BC Pharmacare if you live in BC). In short, if you live outside of BC, the proposed changes won’t put you at a disadvantage.
See also "What is a special authority and what role does it play in getting approval for a Tier 2 drug?"
Engagement process and implementation timing
It appears as though decisions have already been made. Does my input really matter?
Yes, the board is keen to hear from you. This is why the board is engaging with members and providing support materials so that your input is informed. Materials available include a recorded webinar, new video and new website content. The board will consider your feedback in making its decision.
When will changes be made?
We are considering implementing changes in early 2022. Green Shield will contact you directly if you will have reduced coverage of medications for any chronic conditions. The board aims to provide as much notice as possible.
The options the board is proposing offer grandparenting periods to support you in transitioning. The grandparenting option would allow you time to transition to a new drug by as early as January 2023 or as late as January 2027.
If changes are implemented in early 2022, you can then begin consulting your doctor to consider switching to a drug on the PharmaCare formulary or choose to remain on your drug. If you choose to remain on your drug after the grandparenting period and pay the higher out-of-pocket cost, your drug would continue to be covered at a lower co-insurance (Tier 2). If you have a spousal plan, their plan may cover the balance.
Will the survey results be available?
We will share the results with members on the plan website in spring 2021.
In terms of the overall timeline, it seems like a short amount of time to see my doctor and try a new drug. Can you go over the timing generally and explain the process for how I would make a switch?
The proposed options (outlined in the webinar recording) offer a grandparenting period to allow you more time to consider switching your drug for a chronic condition. We recommend the following steps:
- Find out if your drug is covered by PharmaCare by using the formulary search.
- Determine if you can coordinate any benefits coverage (e.g., a spousal plan).
How will decisions be made?
Input from members like you will be one component of the board’s decision making. We will also consider many technical aspects, such as analyzing claims data, benchmarking against similar plans, studying the group benefits contracts, assessing funding status and projections, reviewing administrative expenses and premiums, and educating ourselves as a board about group benefit issues and trends.