Online Drug Claims Frequently Asked Questions

1. What information do I need to submit a prescription drug claim in your Member Profile?

   Before submitting your online drug claim, make sure you have your original pharmacy receipt or a copy of the receipt in front of you. This receipt includes the Drug Identification Number (DIN), drug quantity, day’s supply, drug cost and dispensing fee.

   Pharmacy receipts aren’t always easy to understand. Our lookup tool in Member Profile shows images of actual receipts from British Columbia’s leading pharmacies, to guide you through the claiming process quickly and easily.

2. What types of prescription drug expenses does Member Profile accept?

   Member Profile accepts online claims for prescription drugs with Drug Identification Numbers (DINs), that are registered in our database and covered by your drug plan.

   There are certain drug types and prescriptions that cannot be entered online at this time. You can still mail or drop off a paper claim and receipts for these items:

   1. Compounds (drug ingredients are mixed by a pharmacist to customize your medication)
   2. Medical devices or equipment with DINs (although they have DINs, these must be submitted as health expenses and not drug expenses)
   3. Drugs covered by alternate sources of funding, such as provincial health agencies (for example, BC Cancer Agency, BC Renal Agency, BC Centre for Excellence in HIV/AIDS)
   4. Newly approved DINs that may not yet be entered into our drug database
3. Can I submit drug claims online if I have pay-direct drug coverage?

   Most Pacific Blue Cross benefit plans include pay-direct drug coverage. If you are covered by one of these plans, bring your Blue Cross ID card with you when filling your prescription. The pharmacy will deduct the entire eligible amount of your claim from your bill—you only have to pay what isn’t covered by your plan. This portion is your responsibility and not eligible for online claims.

   If you do not have a pay-direct drug plan or you pay for a prescription without using your pay-direct card, you can submit your claim in your Member Profile.

   To find out if you have pay-direct coverage:

   1. Click on the ‘Benefits’ tab in your Member Profile
   2. Choose ‘Drugs’ from the list of plan benefits
   3. If more than one person is covered by your plan, choose a name from the drop down menu
   4. In the results page, on the right you will see a check box for pay-direct. If this box is checked, then you have pay-direct coverage
4. How do I find out if I am covered for a drug before I claim?

   Sign in to your Member Profile using your policy and member identification number printed on your Pacific Blue Cross ID card.

   1. On the your Member Profile home page you will see a drug lookup tool
   2. If more than one person is covered by your benefit plan, type in the name of the person whose drug you want to look up
   3. Next, type the name or DIN of the drug
   4. Choose from the list of drugs on the results page, to view coverage for different quantities and concentrations

   Note: Your benefit plan may also include markup and dispensing fee limits for prescriptions. Markup is the amount above the manufacturer’s list price; a dispensing fee is what the pharmacist charges for dispensing or mixing your medication at the pharmacy. These are automatically applied when you submit your claim.

5. Do I need to send in my pharmacy receipts?

   If you’re submitting a claim in your Member Profile, you only need to submit receipts if you are selected for receipt verification. If this happens, you will need to send your official pharmacy receipt (or – in the case of coordinated benefits – a copy of the claims statement and receipt showing what was paid by your spouse’s plan) to Pacific Blue Cross to process your claim. Specific instructions will be provided if you’re selected for verification.

6. I coordinate benefits with my spouse. Can I claim remaining expenses that aren’t paid by my spouse’s drug plan?

   Yes. As long as you haven’t already been reimbursed using your pay-direct drug card, you can submit the unpaid portion of your prescription expenses online.

   Separate claims under coordinated benefits must add up to the total shown on your receipt. your Member Profile can recognize duplicate receipts, so be careful not to claim twice for same expense.

7. Can I use Member Profile to apply unpaid prescription expenses to my Health Spending Account (HSA)?

   If you are submitting your entire balance of the pharmacy receipt for claiming online, or your receipt has been partially paid for by another insurance carrier, then YES, you can apply all or a portion of your expense to your HSA.

   You cannot use your Member Profile to apply unpaid drug expenses to your HSA if you’ve claimed for part of the expense using your pay-direct card. The system will treat it as a duplicate claim. Please mail or drop off a standard extended health claim form with receipt for the unpaid expense to Pacific Blue Cross, indicating that you would like to apply the unpaid portion to your HSA.

8. How long will it take to reimburse my claim?

   Member Profile will let you know instantly how much of your total expense will be paid. Funds will be deposited directly into your bank account, usually within 2 – 3 days.