Health Benefits provides coverage for certain pharmacy items and medications. It is important for clients to have access to the medical care that is most appropriate for their health and their medical condition. Prescription and over-the-counter (OTC) items are used to treat short-term illnesses, and are one of the many ways to help patients with chronic conditions live healthier, longer, and more fulfilling lives.
The pharmacy benefit is administered through a partnership between Health Benefits, BC PharmaCare, and PBC. Clients can access detailed information about their pharmacy benefits through BC PharmaCare's formulary search. Additional information about coverage for pharmacy items is available through the online PBC Member Profile.
In addition, multiple provincial agencies including the BC Cancer Agency, BC Transplant, BC Renal Agency, and the BC Centre for Excellence in HIV/AIDS provide specialty pharmacy items to all BC residents living with specific illnesses or conditions.
For the latest pharmacy updates, check out PharmaCare's newsletters.
Health Benefits covers specific pharmacy items and services under the following categories:
• Prescription drugs;• Over-the-counter drugs; and• Non-drug over-the-counter items (e.g., lancets for diabetic use).
• Prescription drugs;
• Over-the-counter drugs; and
• Non-drug over-the-counter items (e.g., lancets for diabetic use).
BC PharmaCare is the primary provider of eligible pharmacy items and services through Plan W. In addition to covering many prescription drugs, Plan W covers some over-the-counter medications and over-the-counter items. PBC provides supplementary pharmacy coverage to some FNHA clients.
• Moved to BC;• Turned 19; or• Married or divorced.
• Moved to BC;
• Turned 19; or
• Married or divorced.
Clients who would like to confirm whether they are enrolled, or who need to enroll with Plan W for the first time, should have their status number ready and call Health Benefits at 1-855-550-5454.
Most pharmacy items are fully covered under the pharmacy benefit. If clients are asked to pay for their medication at the pharmacy counter, it's likely that the item is not covered. Clients should ask their pharmacy provider for a recommendation that is covered by the Health Benefits pharmacy benefit.
Items not listed as a benefit may be covered on an exceptional basis. Clients should call Health Benefits at 1-855-550-5454 to learn more about exceptional coverage.
Brand Name and Generic Drugs
It is important to understand the differences and similarities between brand name and generic drugs.
Brand name drugs are the first version of a drug to be sold within a country and can only be sold by the company that researched and developed the drug (e.g., Tylenol). Brand name drugs are more expensive because of the money invested in research, development and marketing.
Generic drugs are a copy of a brand name drug that any company can sell (e.g., acetaminophen). Generic drugs have the same active ingredients as the brand name drug but cost less because the drug company does not need to invest money in creating it. Generic drugs undergo the same regulatory testing and are just as safe as brand name drugs.
Most public and private drug plans, including Health Benefits, cover a mix of brand name and generic drugs. If there is a medical reason the client cannot take a generic drug on Health Benefits' formulary list, the prescriber may be able to request Special Authority to ensure the medication is covered.
Some items and services covered under the pharmacy benefit require approval before pharmacy providers can bill for them. Approvals for pharmacy items covered under PharmaCare are called Special Authorities. Approvals for pharmacy items covered under PBC are called Prior Authorizations.
Prescribers can submit Special Authority requests directly to PharmaCare, and Prior Authorization requests directly to PBC. If they receive authorization, they can provide the item or service and bill PharmaCare or PBC directly. If PharmaCare denies a Special Authority request, prescribers can resubmit the request with additional rationale.
If clients decide to pay out-of-pocket for an item or service before PharmaCare or PBC has authorized a Special Authority or Prior Authorization request - or despite PharmaCare or PBC denying the request - reimbursements will not be issued.
Pharmacy providers can identify which items and services require approval and which are covered under the pharmacy benefit by checking the Pharmacare Plan W formulary search, or their PBC Provider Portal, “PROVIDERnet." If the provider is unable to determine requirements or coverage, the client or pharmacy provider should contact Health Benefits at 1-855-550-5454.
Some items and services are considered Exclusions under the pharmacy benefit. Clients cannot seek exception or appeal for excluded items. Pharmacy benefit Exclusions include, but are not limited to:
• Alternative therapies (e.g., glucosamine and evening primrose oil);• Anti-obesity drugs;• Certain over-the-counter (OTC) items;• Clinic, physician, and hospital fees;• Cough preparations containing codeine;• Drugs with investigational or experimental status;• Fees for writing prescriptions or completing a form;• Fertility agents and impotence drugs;• Household products (e.g., soap and shampoos);• Megavitamins;• Prescriptions written by a veterinarian; and• Vaccinations for travel.
• Alternative therapies (e.g., glucosamine and evening primrose oil);
• Anti-obesity drugs;
• Certain over-the-counter (OTC) items;
• Clinic, physician, and hospital fees;
• Cough preparations containing codeine;
• Drugs with investigational or experimental status;
• Fees for writing prescriptions or completing a form;
• Fertility agents and impotence drugs;
• Household products (e.g., soap and shampoos);
• Prescriptions written by a veterinarian; and
• Vaccinations for travel.
Pharmacy items must be provided by a licensed pharmacy or medical supplies and equipment provider.
When coverage for a service has been denied, clients have the right to appeal the decision. Items and services that are Exclusions cannot be appealed. See the Appeals page for more information about the appeals process.
Information and forms for pharmacy providers can be found on the Information for Health Providers page.
For information on how to access pharmacy benefits check out the Pharmacy Benefit Fact Sheet.
Here is the Summary of Diabetes Drugs, Insulins, and Supplies Coverage for FNHA Clients.
For information on how to access reimbursement for the Shingrix® vaccine check out the First Nations Health Benefits Shingles Fact Sheet.
1-855-550-5454 (Toll Free)
Download a print version of the FNHA Health Benefits Client Satisfaction Survey
Client Satisfaction Survey FAQs