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How does B.C. PharmaCare synchronize with my group benefits plan?

The lucky residents of beautiful British Columbia are entitled to join the BC PharmaCare program, under the Ministry of Health.

How does it synchronize with your group benefits plan?

First, understand how PharmaCare works:

  • The province will pay 70% of drug expenses, after you have spent your deductible.
  • The deductible is 0-3% of household income, depending on your income.
  • The out-of-pocket maximum is 2-4% of household income, depending on your income.
  • After you’re paid 4% of your HH income out of pocket, the plan will cover 100% of expenses.

Here’s a calculator from the Ministry’s website that can help you determine what your deductible is.

  • You have to inform the insurer of your BC PharmaCare registration number

If you switch to The Cooperators Life Ins Co, they will send you a letter requesting that you send in your registration number. You can fax it or mail it in, and it will be saved in your computer file.

(If you fail to send it in after repeated communication attempts, your claims will be suspended until you send it in).

  • The computer system keeps track of everything

When you need to buy drugs, the pharmacist would bill both the provincial plan, and your group plan, to see who will pay for the drug.

Example

Let’s say your benefit plan covers 90% of drugs, to a maximum of $2,000.

Say your drugs every month cost $1,000, and your income is $50,000. Your deductible is 3% of that, or, $1,500 per year. Your family max is 4%, or $2,000.

First Quarter 

In January, your pharmacist needs to submit a 3-month supply, or $3,000 worth of drugs to each insurance plan.

BC PharmaCare rejects it because the deductible has not been satisfied yet.

The group plan would reimburse $2,000, leaving you out of pocket $1,000. You pay the pharmacist $1,000, and the computer system keeps track that you have paid that amount towards your deductible.

Second Quarter

After 3 months, you need to pick up another supply of $3,000.

Your group plan rejects it because the drug maximum has been reached.

You must pay $500 towards the purchase, in order to reach your annual deductible of $1,500.

BC PharmaCare pays 70% of $2,500, or $1,750. The remainder is $750. ¬†However, your family max is $2,000, and BC won’t allow you to incur more than $2,000 of expenses. Therefore, you contribute another $500, and BC covers 100% of the remaining $250.

Now, your total out-of-pocket cost for the year is $2,000 and any future drugs you buy are covered by BC at 100%.

Third Quarter

After another 3 months, you need more prescription drugs at a cost of $3,000.

BC pays 100% of the cost and you pay $0.

Fourth Quarter

Another $3,000 of drugs needed – BC pays 100% and you pay $0.

It starts all over again at the beginning of the next year.