| ....Insurance questions are frequently asked at pharmacies, especially at the beginning of the year when people need to reach their deductible before their insurance pays for a portion of their drug cost. More often than not, it is some of the terminology that confuses people. This article will review some of the terminology and related questions pertaining to insurance plans including Pharmacare and help you better understand your insurance coverage.
1) What is a deductible anyways?
....A deductible refers to the amount of money one must spend before the insurance plan will start paying for one’s medication. Pharmacare bases an individual’s deductibles on their previous year’s taxable income. A consent form must be sent to Pharmacare to give them permission to access this information. A person must file their taxes or Pharmacare cannot set a deductible for them and the person will automatically be assigned the maximun deduction set be Pharmacare. Deductibles usually run per calendar year, so every January it starts over again. Some private plans have their deductible start when the individual started qualifying for benefits at his/her work. As such, the deductible may start over any time of the year.
You may contact your benefit provider for additional information.
2) What is a plan maximum?
....Some private drug plans simply have a maximum amount that one can claim in a year. After that amount, the patient is responsible for the full cost. Luckily, Pharmacare does not follow this policy.
3) What is an annual maximum ceiling?
....Pharmacare uses this term and it can be quite confusing. Once a person reaches his/her deductible Pharmacare pays for a percentage (usually about 70%) of the medication cost. Once a person reaches his/her annual maximum ceiling, Pharmacare goes one step further and pays up to 100% of the medication cost. In other words, the maximum is a level set by Pharmacare, that once reached, results in Pharmacare paying all (or nearly all) the medications costs for a person. |
4) Low Cost Alternative (LCA) or
....Reference Based Drugs (RBD)
....All insurance plans, including Pharmacare, have a list of medications that they will provide coverage for their clients. For various reasons, some medications are not covered by Pharmacare or private insurance plans. The client is then ultimately responsible for 100% of these drug costs. It is important to phone your benefits provider as there are exceptions to the rule.
5) Low Cost Alternative (LCA)
....Many brand name drugs have generic equivalents on the market. Pharmacare and many private insurance plans will only pay up to the drug cost for the least expensive alternative available for a particular drug. If the client wants the more expensive brand name, he/she will be responsible for the difference in price.
6) Reference Based pricing
....Pharmacare groups a whole class of similar medications under one umbrella and will only pay up to the drug cost of the least expensive one. Again, the patient is responsible for paying the difference if he/she is not prescribed the referenced based drug for that class of medication. There are only a couple of drug classes where reference based prices applies in B.C. This brings us to the next question.
7) What is a special authorization request/form?
....There are some circumstances when a drug will be covered by Pharmacare if the client satisfies a specific set of criteria for coverage. This is the responsibility of your physician. The physician needs to initiate the process by filling out a form letter giving his/her reasons why the client should qualify for coverage. This special authorization request can often take up to 1 week to process. If deemed acceptable, the drug then qualifies for normal coverage under Pharmacare for that client.
Your Peoples Pharmacist is not only a trusted source of health information, but also for matters related to drug insurance plans. We would like to remind people to check first with their insurance policies and providers as well if they have any questions. Come in today to see how your Peoples Pharmacist can help you live a better life. |
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