Not always easy to know what drugs are covered by your health care plan

The Report: August 1999 vol.20 num.2


As a Labour Relations Officer on phone duty I have received numerousinquiries from members about their Blue Cross coverage for prescription drugs.

The Blue Cross list of -covered" medications is based onPharmacare recommendations. Pharmacare has a very long list that is updated daily. Whiledoctors do not have access to this list on a daily basis, pharmacies have access to itimmediately through their on-line system.

When a new drug comes on the market after approval by Health Canada(who look at safety and efficiency but not cost), the drug manufacturer has the option ofsubmitting the drug to Pharmacare for approval. If they do not submit the drug, it willnever be covered. This explains why some drugs might be available for your physician toprescribe but are not reimbursed by Blue Cross.

A medication may be on the market for a few months before themanufacturer decides to submit the medication to Pharmacare for consideration under theirdrug approval process, and once submitted the process takes three to four months tocomplete. It will remain uncovered for this period.

If you wish to find out whether a medication regularly prescribed byyour doctor is covered before you get the prescription filled, you can always contactPharmacare directly at 682-6849 (Vancouver and Lower Mainland), 952-2866 (Victoria), ortoll-free 1-800-554-0250 (rest of BC). This is their general information line, open sevendays a week from 8 a.m. to 8 p.m. Evenings are a less busy time to call. You can tell themthe names of your drugs and they will tell you whether or not they are covered.

If your doctor prescribes a new medication for you, either you or yourdoctor can make the call to see whether or not the prescription is covered by Pharmacareand hence by Blue Cross. If you get to the pharmacy without making the call, ask yourpharmacist. They are instantly linked to the information when they put your drug intotheir database and can immediately tell you if your drug is covered, or if there is alow-cost alternative (LCA) that would be. Of course they cant change theprescription without talking to your doctor, but at least you would know and could askthem to check with your doctor as to whether the LCA would meet your medical needs.

If you have had a -non-benefit" (not covered) drug prescribedand your physician insists that it is the only drug that will do the job for you, youshould be able to get the drug covered by receiving a special authority from Pharmacare.All doctors offices have the forms to apply for this special authority. They simplyfill out the form and make the argument as to why you need this specific drug. OncePharmacare has approved the drug, you must then let Blue Cross know that you have beengranted a special authority.