Frequently Asked Questions

1. How does a pay-direct drug plan work?

   Present your Pacific Blue Cross ID card to your pharmacist when filling a prescription and you will only be charged for expenses not covered by your plan. Note: you do not need to send your receipt to Pacific Blue Cross.
   
   

2. What is Blue RX?

   Blue RX is a customized drug plan called a managed formulary. A formulary is a list of drugs covered by your plan. It is called a “managed” formulary because new drugs are reviewed to ensure they are both clinically and cost effective before they are added to the plan.

   The Blue RX drug plan provides you with safe, high quality prescription drugs at an affordable price, and helps you, your union and employer to control rising drug costs. Download the Blue RX information sheet
   
   

3. What is covered under my Blue RX plan?

   Blue RX covers brand name and generic prescription drugs used to treat all major diseases and conditions. For some conditions where multiple drugs are available, only the drugs that offer the most cost-effective treatment are covered by the plan.

   Certain drugs will require prior approval from Pacific Blue Cross or BC PharmaCare before they are eligible for coverage. This is to make sure less expensive, first line or alternative therapies have been considered before switching to more expensive drugs. This helps protect your drug plan from higher costs while ensuring you receive effective treatment for your health condition.

   To see a list of drugs that need prior approval, visit www.pac.bluecross.ca/bluerx.
   
   

4. What drugs need prior approval to be eligible for coverage?

   With your Blue RX plan, your pharmacist can submit your drug claim electronically to Pacific Blue Cross on your behalf. The pharmacist will alert you if prior approval is needed. Depending on the drug, approval may be required either by Pacific Blue Cross or by the BC PharmaCare Special Authority program.

   Before going to the pharmacy, visit www.pac.bluecross.ca/bluerx. There you will find a complete list of drugs that need prior approval for coverage from either Pacific Blue Cross or the BC PharmaCare Special Authority program.

   While BC PharmaCare has an extensive list of drugs requiring special authorization, Pacific Blue Cross only requires that you obtain special authorization for certain drugs on their list. Here's a list of drugs that requires Special Authorization from Pacific Blue Cross.
   
   

5. How do I apply for prior approval?

   Step 1:

   Visit Member Profile to find out if your drugs require prior approval. You must enter the drug you are being prescribed to determine if prior approval is required. For a comprehensive list of drugs, visit www.pac.bluecross.ca/bluerx.
   
   

   Step 2:

   Print a copy of the Blue RX Prior Approval form specific to the drug coverage you are requesting.
   Forms are available through Member Profile or you can request them from us at 604 419-2000 (toll-free 1 877 722-2583) between 8:00 a.m. and 4:30 p.m., Monday through Friday.
   
   

   Step 3:

   Complete the first part of the form and have your doctor complete the remainder of the Blue RX Prior Approval form and send it to Pacific Blue Cross by fax 604 419-2000 (toll-free 1 877 722-2583) or mail:

   
   Pacific Blue Cross
   PO Box 7000
   Vancouver, BC V6B 4E1
   
   Where applicable, if your doctor is a specialist for your condition, he/she does not need to complete the form. Simply add the name of the specialist to the form or, if you have already filled the prescription, attach a copy of your pharmacy receipt showing the specialist’s name and send it to us.
   
   

   Step 4:

   Pacific Blue Cross will confidentially review the information and inform you of the decision.
   
   
   

6. How do I know if PBC has approved my prior authorization request?

   1. Login to Member Profile
   2. Click the Member tab
   3. Go to Preauthorizations: Authorized Products and Services
   4. Click the Drugs tab (middle of the screen) and all pre-authorized drugs will be listed

    

7. What is Lowest Cost Alternative?

   If you are prescribed a brand name drug, you will be reimbursed for the cost of the lowest priced generic equivalent. A generic equivalent has the exact same active ingredients as the brand name, at a much more affordable price for you and your drug plan.

   Visit www.pharmacycompass.ca to compare per-pill costs for both generic and brand medications at pharmacies in your area.
   
   

8. What is markup and how does it affect my coverage?

   Markup is the total percentage added by a pharmacy to the manufacturer’s list price of a drug. Some pharmacies charge higher markups than others. Your Pacific Blue Cross plan reimburses according to markup limits set by BC PharmaCare.

   Visit www.pharmacycompass.ca to compare per-pill markups at pharmacies in your surrounding area.
   
   

9. What is the maximum dispensing fee under my plan?

   A dispensing fee is the amount charged to you by the pharmacy for dispensing the drug. Like markups, some pharmacies charge higher dispensing fees than others. Your Pacific Blue Cross plan reimburses according to dispensing fee maximums set by BC PharmaCare.

   Visit www.pharmacycompass.ca to compare per-pill markups at pharmacies in your surrounding area.
   
   

10. What if my prescription is not covered?

    Ask your doctor to recommend a drug covered by BC PharmaCare that could also treat your condition.

    If your drug is eligible for Special Authority coverage (your pharmacist will know), ask your physician to apply to BC PharmaCare for Special Authority approval of your drug. If BC PharmaCare accepts your application, then Pacific Blue Cross will also cover the drug.

    We require documentation that BC PharmaCare has approved your drug.

    How to apply for Special Authority.
    
    

11. What if I refill my existing prescription and it is not covered by Blue RX?

    If you fill a prescription for a drug that is not included in the Blue RX formulary, your EHC plan may not cover it.
    
    

12. I believe my doctor already applied for Special Authority approval with BC PharmaCare, but I am not sure. How can I find out if I am approved?

    You can obtain verbal confirmation over the telephone from Health Insurance BC (HIBC) at:

    604 683-7151 on the Lower Mainland or
    toll-free in BC at 1 800 663-7100
    or ask your pharmacist.

    Please be prepared to provide your name, Personal Health Number (PHN), birthdate, and current address. Your pharmacy can also confirm if a special authority approval is in place when filling your prescription. If approved, and if your pharmacy offers real-time Special Authority confirmation, there is no further action required. PBC will receive the approval information in real-time from the pharmacy and the eligible claim amount will be deducted from your bill.
    
    

13. I know that Special Authority for my prescription was approved. Now what do I do?

    Simply visit any pharmacy offering real-time Special Authority confirmation and present your pay direct card. The eligible claim amount will be deducted from your bill.

    Find BC pharmacies offering real-time Special Authority confirmation at: www.pharmacycompass.ca
    
    

14. Are doctor’s fees for completing the Prior Approval or Special Authority forms covered by Pacific Blue Cross?

    No, these fees are the responsibility of the patient. However, doctors should not charge patients to complete BC PharmaCare Special Authority applications.
    
    

15. Many of the medications covered by Blue RX and BC PharmaCare are the less costly generic forms of the medications. Are generics as good as brand name versions?

    Yes. Please see our article about this.
    
    

16. I have previously tried the medication covered by Blue RX and it was not agreeable with me. I prefer to stay on a drug that is not included in the Blue RX formulary. Will it be covered?

    We suggest you seek your physician’s advice regarding what is the best medication for you, whether or not it is covered by your plan.
    
    

17. Can my doctor or I write to Pacific Blue Cross to get the ineligible drug covered?

    No. Pacific Blue Cross only administers the claims for eligible drugs as bargained by your union and employer. Pacific Blue Cross does not have the power to override this agreement.
    
    

18. My medication is not covered and I have been declined for Prior Approval. What can I do?

    For medication not covered under Prior Approval, once you have submitted the required forms we suggest you seek your physician’s advice regarding what is the best medication for you. Under the Income Tax Act you may be eligible to seek a deduction for eligible medical expenditures over a defined level.
    
    

19. BC Pharmacare has announced changes to coverage for some biologic originator medications. Will this impact me?

    If you are currently prescribed one of the originator medications for which BC Pharmacare is discontinuing coverage (for example, Remicade® or Enbrel®, Rituxan®), you must be transitioned to the biosimilar medication by your physician in order to maintain BC PharmaCare and ongoing Pacific Blue Cross coverage. This cannot be done at your pharmacy, you must contact your physician. Neither BC PharmaCare nor Pacific Blue Cross will continue to reimburse for these originator medications after the date outlined on the BC PharmaCare website.
    
    

20. What if my doctor feels it isn’t appropriate for me to transition to a biosimilar medication?

    If your doctor feels that a transition isn’t medically appropriate, a Special Authority request for continued coverage of the originator drug can be submitted to BC PharmaCare. These requests for continued coverage will be reviewed by BC PharmaCare on a case-by-case basis. Pacific Blue Cross will honour the decision of the review.
    
    

21. Are biosimilars safe and effective?

    Yes, for a biosimilar to be approved in Canada, Health Canada must find no meaningful differences in safety and effectiveness compared to the biologic originator drug. We encourage you to find out more about biosimilars, including a list of frequently asked questions, by visiting www.gov.bc.ca/biosimilars.