1. When do these new coverage limits take effect?

   The coverage limits take effect on January 1, 2021.

Vision Coverage

1. Is there a dollar allotment specific to the cost of eye examinations or does the cost of the eye examination and the cost of glasses come out of the same pot, to a maximum of $250 every two years?

   Vision wear (glasses, frames, lenses, contacts) is allotted $250 every two calendar years. Eye exams are considered a separate benefit and is allotted $75 every two calendar years.

Paramedical reimbursement

1. What does the term “paramedical” encompass? Under ‘Practitioner Services” it appears that this includes acupuncturist, chiropractor, counsellor, massage therapists, naturopaths, nurses, physiotherapists, podiatrist. Is this the full list?

   Paramedical services refer to treatments rendered by health care providers such as the ones listed above. The paramedical practitioners covered under the MPP are the following: Acupuncturist, Chiropractor, Massage therapists, Naturopaths, Physiotherapists, Podiatrist/Chiropodist, and Psychologist, all of which must be registered in the province of practice.

2. Currently, we are reimbursed 70% up to $1,000 claims per person per calendar year. This is further broken down to, for example, registered massage therapy (RMT) and registered physiotherapy (RPT) services have combined limit of $600 per person per calendar year. With the announced benefit improvement, does this mean that there will be a $500 allowable for each RMT and RPT?

   Correct. You will have $500 available for Registered Massage Therapists and another $500 available for Registered Physiotherapists.

3. Is there a maximum claim limit for the combination of all paramedical services per person per calendar year? What is the maximum claim limit?

   Paramedical services are no longer combined. There is now a $500 maximum per practitioner, per person, per calendar year.

Shingles vaccine

1. Are both Shingrix (2 doses) and Zostavax II covered?

   Yes

2. Is Shingrix covered if the person has already received Zostavax II?

   Yes.

3. Does the person require a prescription from a physician that must then be taken to the Pharmacist for provision of the shingles vaccines?

   Pacific Blue Cross follows prescription requirements in the jurisdiction in which the drug is being dispensed.  In BC, this is set by the College of Pharmacists of BC. 

   Vaccines that are part of a routine immunization program do not legally require a prescription from a physician and can be dispensed from the pharmacist without the need for a physician visit.  In the case of the shingles vaccine, this results in different prescription requirements based on the age of the member. 

   Following BC regulations, anyone over 50 years of age would not require a prescription from a physician.  Anyone seeking the shingles vaccine who is under 50 years old would require a physician’s prescription.  This requirement is well understood by physicians and pharmacists, and members under 50 would be assisted by their health care professionals to navigate this, if the shingles vaccines was recommended by their physician.

4. If a person receives the vaccine at a Travel Clinic will it be covered?

   Yes. Receipts must include the vaccine name, drug identification number (DIN), name of patient, date of service, amount charged, and name of supplier (physician’s office, pharmacy or travel clinic).

5. Is the Shingles vaccine covered at 70% like other prescriptions?

   Yes.

6. Are there any restrictions on the Shingles vaccine coverage that we should be aware of?

   Only the cost of the vaccine (plus eligible dispensing fee) would be reimbursed.  Charges for a clinic appointment or the administration of the vaccine would not be eligible for reimbursement.

Dispensing fee changes

1. If I, or my dependents, are already on a drug or drugs that will be affected by the dispensing fess changes, will I receive further communication?

   Yes. Pacific Blue Cross has identified plan members that currently have prescriptions for drugs affected by the dispensing fee changes. These members were sent additional information in the mail in the month of November 2020.

2. What is the current practice? Most maintenance medications are given on a 90-day basis, so 4-5 times per year. Those with blister packs would be issued on a 30-day basis, so 12-13 times per year.

   Pacific Blue Cross recommends filling a 3-month supply of prescriptions for chronic medical conditions. This saves the member money on dispensing fees and reduces the need to visit the pharmacy.

   The industry standard for both public and private insurers is to implement policies that promote filling a 90-100 day supply of prescriptions for chronic medical conditions. The most common dispensing interval for members requiring blister packs is 28 days.

3. Would this affect dispensing fees for new medications or new doses of medications where usually a trial period of less than 90 days is used?

   The dispensing fee limits only apply when the dose of a medication has not changed since the last refill. For example, if someone is on a maintenance drug, say metformin, and the dose is being gradually increased, dispensing fee limits would not apply.

4. Would all my medications be impacted by the new dispensing fee limits?

   No. Only oral forms (tablets and capsules) of medications on a specific Maintenance Drug list will be impacted, and only if you’re on a dose of the medication that has not changed since the last refill.

5. How do I know which of my medications are impacted by the new dispensing fee limits?

   Maintenance drugs that are subject to these limits generally fall into the following categories:

   • Drugs for stomach acid related disorders (e.g. omeprazole, pantoprazole, ranitidine)
   • Drugs for diabetes (e.g. metformin, gliclazide, linagliptin)
   • Drugs for common heart conditions (e.g. ramipril, atorvastatin, metoprolol, rivaroxaban)
   • Hormone replacement therapy (e.g. estradiol, conjugated estrogen, progesterone)
   • Drugs for osteoporosis (e.g. alendronate, risedronate, raloxifene)
   • Drugs for depression and anxiety (e.g. citalopram, amitriptyline, venlafaxine)
   • Drugs for bladder conditions (e.g. oxybutynin, tolterodine)
   • Drugs for Benign Prostatic Hyperplasia (e.g. finasteride, tamsulosin)
   • Drugs for Thyroid Conditions (e.g. levothyroxine, methimazole)
   • Gout Therapy (e.g. allopurinol, febuxostat, colchicine)
   • Drugs for chronic inflammatory conditions (e.g. methotrexate, leflunomide, mesalazine)
   • Drugs for chronic lung conditions (e.g. theophylline, montelukast, roflumilast)

   You can use the drug look up tool on Member Profile or the member app to see which of your medications is impacted by this change. We encourage you to speak to your pharmacist to ensure a smooth transition for your prescriptions effective January 1, 2021.

6. What if I’m on an impacted drug and don’t want to reduce how often I get my prescriptions filled?

   You can continue getting these prescriptions filled more frequently than the coverage levels permit, but you will be responsible for paying the additional dispensing fees. The plan will continue to cover the cost of the drug in accordance with the terms of the Retiree Benefits Plan.

7. Is there a summary table of what has changed in relation to the dispensing fees (e.g., what currently is covered and what will be covered in January 2021)?

    

   Drug type	Prior to January 1, 2021	After January 1, 2021
   Maintenance drugs	No limits on dispensing fees	Maximum five dispensing fees annually; if you meet certain criteria* your annual maximum will be 13 dispensing fees
   Chronic drugs	No limits on dispensing fees	Maximum 13 dispensing fees annually
   Acute drugs	No limits on dispensing fees	No limits on dispensing fees

    

   *Members that automatically qualify for monthly fills or blister packaging for medications have a maximum limit for drugs on the Maintenance Drugs list increased to 13 dispensing fees per year. To qualify members are:

   • are 90 years of age or over, or
   • use seven or more drugs to manage chronic conditions, or
   • use four or more drugs to manage chronic conditions if one of more are used to treat psychoses, bipolar disorder, Alzheimer’s Disease, Parkinson’s Disease, or epilepsy.
8. Are there any qualifications placed on who can have their medications in a blister pack and have the dispensing fees covered (i.e. age-related, # of drugs, etc.)?

   Yes. This information was included in correspondence sent to affected members.

   Members that automatically qualify for monthly fills or blister packaging for medications have a maximum limit for drugs on the Maintenance Drugs list increased to 13 dispensing fees per year. To qualify members are:

   • are 90 years of age or over, or
   • use seven or more drugs to manage chronic conditions, or

   use four or more drugs to manage chronic conditions if one of more are used to treat psychoses, bipolar disorder, Alzheimer’s Disease, Parkinson’s Disease, or epilepsy.

9. If a person currently receives their medications in a blister pack, is the dispensing fee for every medication included in the blister pack covered every four weeks?

   If you qualify for 13 fills annually this dispensing fee limit will be applied to all medications taken on a regular basis (both chronic and maintenance drugs). Please note that each medication must meet the criteria in order to be eligible for the blister pack.

Amending coverage of medical supplies

1. What are the requirements that need to be met to claim medical supplies or devices? Does it need to be purchased from a drug store or specialty store or can it be purchased anywhere, such as when outside of Canada on Amazon.ca?

   Claiming requirements vary depending on the type of medical equipment. Our authorization is required for items that cost more than $5,000. Items must be purchased by an authorized medical supplier.

   • Pharmacies, including those contained within big box stores, can provide medical supplies.
   • There must be a physical store where members can purchase the medical supplies, even if it is primarily a web-based medical supplier.
   • The store must issue receipts that include the company name, address, phone number, patient’s name, name of the medical supply (including the make and model), and the price and taxes (if charged) are listed separately.
   • The store must have a business license to operate in the community where it is located.
   • Medical supplies purchased from a web-based medical supplier with a store located outside Canada are not eligible.
2. Is there a maximum amount that can be claims for medical supplies per calendar year? If so, what is it?

   Medical equipment dollar maximums may vary depending on the item. Please contact our call center to confirm details, or submit a pre-authorization.