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Extended Health Care FAQ

Extended Health Care Benefits Frequently Asked Questions

Please click on a question below to see the answer.

  1. How do I submit a claim for Extended Health benefits?
    Here are the instructions for submitting claims under your Extended Health Care plan. Follow this link if you need information on how to submit a dental claim.

    1. Obtain an Extended Health Claim Form
    2. Fill out the claim form
    3. Attach receipts and any required supporting documents to the claim form
    4. Send the claim form, along with receipts and any required documents to:
      Pacific Blue Cross
      PO Box 7000
      Vancouver, BC V6B 4E1
      Or drop the claim off in person at:
      4250 Canada Way
      Burnaby, BC V5G 4W6
    Please note: we are unable to return original receipts. If you will need to submit a claim to another health benefits carrier, make a photocopy of the receipts.
  2. Where do I get an EHC claim form?
    There are multiple ways to obtain a claim form:
  3. What happens after I submit my claim?
    Pacific Blue Cross will reimburse all eligible expenses, subject to the plan deductible and limits, at your plan percentage. Once we've processed your claim, we will mail you a cheque and/or an Explanation of Benefits (EOB) statement. We encourage all of our members to register for CARESnet, our self-service access to plan and benefits information. CARESnet allows you to register for direct deposit and to receive your EOBs online Visit CARESnet, our self-service access to claims and benefits information, to learn more about your benefits.
  4. How do I appeal a claim decision?
    If you wish to appeal a decision about a recent claim, contact our Call Centre. Often an appeal can be avoided by simply providing you with more information about your claim or what is covered by your plan.

    If one of our service representatives is unable to resolve the matter with you, they can escalate your request to a Benefit Review Committee for further review. They will explain how to file an appeal and help you to provide all relevant information regarding your claim.
  5. Do you return receipts?
    Original receipts will not be returned. If you have coverage with another insurance carrier please photocopy your receipts prior to submitting your claim to Pacific Blue Cross. You will receive an Explanation of Benefits (EOB) statement for each claim you submit. Members are encouraged to visit CARESnet and sign up for Direct Deposit and to receive EOB's online. Retain the EOB statement for income tax purposes.
  6. Do you accept photocopies of my receipts?
    Original receipts are required to process your claim. However, in cases where you submit your claim to another insurance carrier first, we will accept photocopies of the original receipts if you include the "Explanation of Benefits" (EOB) from the other carrier with your claim.
  7. Who should complete the Accident or Injury Reimbursement Agreement?
    Any member who submits accident-related claims to Pacific Blue Cross should complete this form.
  8. Why is it necessary to complete the Accident or Injury Reimbursement Agreement?
    The additional details you provide in this agreement allow us to assess the situation and ensure your health or dental plan is not covering costs that should be paid by another party. By signing the reimbursement agreement, you acknowledge your responsibility to recover the funds advanced by Pacific Blue Cross if you are legally entitled to do so.
  9. What difference does it make who pays for the accident-related claims?
    According to the by-laws and contracts covering Pacific Blue Cross’ health/dental plans, claims resulting from the negligence of a liable third party are not eligible. These expenses must be paid by the at-fault party or their liability insurer. These claims are excluded from Pacific Blue Cross health/dental plans to protect your health or dental plan and ensure you continue to have access to health or dental coverage.
  10. Why does Pacific Blue Cross advance the funds for claims that have been identified as accident-related if they are not covered?
    Pacific Blue Cross does not delay reimbursement of claims identified as accident-related because we don’t want to cause financial stress for our members. Furthermore, it is not always immediately apparent whether or not claims should be covered by Pacific Blue Cross. We advise all our members to submit their accident-related claims for reimbursement before the claiming deadline of their health/dental plans unless they are guaranteed reimbursement from the liable party/insurer within a timeframe that will not cause them financial hardship.
  11. What if my accident was deemed to be Low Velocity Impact (LVI)?
    If your accident is deemed to be LVI, please enclose a copy of your letter from ICBC advising of their decision regarding the accident together with your completed reimbursement agreement. If your accident-related claims are not covered by ICBC because the accident was designated to be LVI, we will require this documentation so that we can cover your claims.
  12. What is PharmaCare?
    The Government of British Columbia subsidizes eligible prescription drugs and designated medical supplies, protecting British Columbians from high drug costs, through the BC PharmaCare program. PharmaCare provides financial assistance to British Columbians under Fair PharmaCare and other specialty plans.
  13. What is Special Authority and how do I apply for it?
    The Special Authority program is part of the BC government's PharmaCare program. It approves funding for certain drugs following an application from your doctor. However, before your doctor can apply for this funding on your behalf, you must be registered with PharmaCare.
  14. How do I register for PharmaCare?
    Register for PharmaCare online at www.health.gov.bc.ca/PharmaCare or by phone at 604-683-7151 (toll-free 1-800-663-7100) Monday to Friday 8 a.m. to 8 p.m. and Saturday 8 a.m. to 4 p.m

    You will need:
    • Personal health number
    • Date of birth
    • Social Insurance Number
    • Your Tax Return from your Notice of Assessment from 2 years ago
    • The amount of UCCB (line 117) from your Income Tax Return from 2 years ago
    Reimbursement for a Special Authority drug is subject to your PharmaCare deductible. The amount of your PharmaCare deductible is based on your family income. After you reach your deductible, PharmaCare will pay 70% of your family's eligible costs for the rest of the year until you reach your family maximum. After you reach your family maximum, PharmaCare will cover 100% of your eligible costs. Amounts not reimbursed by PharmaCare may be eligible under your Extended Health Care plan.
  15. How do I obtain coverage for a Special Authority drug?
    Once you have registered for PharmaCare, and provided the drug you require is eligible for Special Authority coverage, your doctor must fill out a Special Authority Request form, and apply to PharmaCare on your behalf. The forms are available online, but most doctors' offices will have copies on site.

    A full list of eligible Special Authority drugs is available at http://www.health.gov.bc.ca/pharmacare/sa/criteria/genericbrandtable.html
  16. Who needs to complete and submit the Special Authority Request form?
    All forms must be completed by a licensed physician and faxed to the number indicated on the form.
  17. How will I know if PharmaCare approves my application?
    They will notify your physician by fax or by mail, and he/she is responsible for contacting you and providing you with a copy of PharmaCare's decision document.
  18. When should I apply for coverage through PharmaCare? Can I submit old claims?
    Special Authority must be in place before you purchase a drug. Coverage cannot be provided retroactively. It's important that you apply as soon as possible. Your claims statement and your pharmacist will be let you know when a drug you have been prescribed is eligible under PharmaCare's Special Authority program.
  19. Why does my plan pay for some prescriptions and not others?
    All plans are designed differently and may include different benefits. For example, some plans only allow prescription drugs covered by the provincial drug plan (PharmaCare) while other plans allow prescription drugs regardless of the provincial plan's coverage. Visit CARESnet, our self-service access to claims and benefits information, to learn more about your benefits. You can also refer to your policy benefit booklet for coverage information.
  20. Is there a limit to how much of a supply I can get for my prescription?
    Yes, all prescription drugs/medicines are limited to a 100-day supply, which is consistent with BC Fair PharmaCare's limit.

    Exceptions will be considered, up to a maximum of 200-days supply, only when required for vacation supply or if your residence is in a rural area and in excess of 2 hours from the nearest pharmacy. If you have pay direct drug coverage, your pharmacy can submit the excess supply online. If you are submitting manually, you must include a note with your submission indicating the reason for the excess supply (vacation or rural area).
  21. My spouse also has extended health coverage. Which EHC plan should we use?
    People who are covered under more than one plan are required to submit their claims to their own plan first. Any remaining balance may be claimed through the spouse's plan.

    Spouse Claims
    When your spouse has an EHC plan through another policy holder/employer, the claim should be handled as follows:
    • Your spouse should pay for the expense, take a photo copy of the receipts and then submit the original receipts to his/her own plan. Once you receive the explanation of benefits from the other plan, you can submit the photocopied receipts with the explanation of benefits to Pacific Blue Cross to claim the remaining balance.
    • If your spouse's EHC plan has a pay direct card, the pharmacist will submit to his/her plan electronically. The pharmacist will issue a paper receipt showing the amount that the plan pays. You can submit the paper receipt to Pacific Blue Cross to claim the remaining balance.

    Dependent Children Claims
    For dependent children, the plan that pays first is determined by the birth date of the parents, as follows:

    • If your birth date is prior to your spouse's in the calendar year, your plan is the first payer and your children's expenses must be claimed through your own plan first.
    • If your spouse's birth date is prior to yours in the calendar year, then your spouse's plan is the first payer for your dependent children. In that case, you must pay for their expenses, take photocopies, and submit the original receipts to your spouse's plan first. Any remaining balance can be submitted to Pacific Blue Cross, along with the photocopied receipts and the explanation of benefits from the other plan, for reimbursement.
    • If your spouse has a pay direct drug card, and your spouse is the first payer, your children's prescription drugs can be submitted electronically using your spouse's pay direct card.
    • If your spouse's EHC plan has a pay direct card, the pharmacist will submit to his/her plan electronically. The pharmacist will issue a paper receipt showing the amount that the plan pays. You can submit the paper receipt to Pacific Blue Cross to claim the remaining balance.

    When completing the EHC claim form, please ensure that you indicate both of the EHC plan numbers.

    The primary plan should be indicated on the top left hand corner of the claim form and the secondary policy and identification number should be indicated at the bottom of the claim form, where it asks "Do you or any other dependant have any other insurance to cover these benefits?"
  22. How do I notify PBC of my change of address?
    At this time, address change requests are handled via e-mail or telephone. Please provide us with your old address and new address. We will be happy to assist you in updating your address.
  23. How do I update my coordination of benefits (COB) information?
    It's important to always keep us up to date with your latest coordination of benefits information because it will ensure we adjudicate your claims with your most recent information.

    The best way to notify Pacific Blue Cross when there are changes to another plan you are also covered under is when you submit your next claim. Identify in a note the specific detail(s) that changed. Be sure to advise whether the changes apply to your dental plan, extended health plan or both so we can make sure we continue to pay all your claims correctly.

    Remember to also update your service providers if they prepare or submit claims to us on your behalf.

    Patients sometimes have coverage under more than one extended health plan or more than one health benefits carrier. In these cases, the patient can submit the expense under both plans to get up to 100 percent of their expense covered. This is called coordination of benefits.
  24. What is my claiming deadline?
    There are multiple ways to find out the specific claiming deadline for your plan:
    • Visit the Plan Information page on CARESnet.
    • Refer to your employee benefit booklet.
  25. How do I submit an out of country claim?
    If out of province medical expenses have been incurred, please follow these instructions on how to submit an out-of-country claim. Ensure you take copies of your receipts/invoices, prior to submission, for your records.
  26. Do I need extra coverage for traveling?
    We recommend additional coverage when traveling, as your group plan may have a lifetime dollar maximum. Please visit the Plan Information page on CARESnet, our self-service access to plan and claims information. You can also contact our Customer Services department at 604 419-2600 or 1 888 275-4672 for further information about your group plan's coverage while traveling outside of your province of residence.

    If you want to purchase travel insurance please call our Individual plans department at 604 419-2200 or 1 800 873-2583, or purchase travel coverage directly from our website.
  27. Are orthotics covered under my plan? How do I claim for orthotics or orthopedic shoes?
    All plans are designed differently. You can learn more about your plan coverage through CARESnet, our secure online access to benefit information for members. Pacific Blue Cross has revised its claiming criteria for members who have custom foot orthotic or orthopedic shoe coverage as part of their extended health care plan. Follow the checklist below when filing a claim:
  28. How do I print my own ID Card?
    Members can print replacement ID cards by signing in to CARESnet and choosing the option to print your ID card. You will need Adobe Reader installed on your computer.
  29. What and how much are reasonable and customary limits?
    Reasonable and customary limits are the amount your health plan will pay based on the range of usual fees for comparable medical services in a geographic area. If your provider charges more than the reasonable and customary limit, you will be responsible for paying the difference.

    Ranges can vary based on whether you have a medical condition that warrants non-standard therapy.

    Like other health benefit providers, Pacific Blue Cross reviews and uses reasonable and customary limits on a continual basis to determine maximum eligible amounts for health care services and supplies covered by your plan. Smart shopping for health care products and services helps members by reducing out of pocket expenses and helps employers reduce benefit plan costs.

    View reasonable and customary limits for paramedical coverage (pdf).
  30. Do you accept claims from all paramedical practitioners or only those who are registered?
    Pacific Blue Cross will only accept claims from paramedical practitioners (massage therapists, chiropractors, physiotherapists, acupuncturists...etc) who are registered with the applicable regulatory board for their type of practitioner, and this is subject to your plan's restrictions or limitations.
  31. How do I determine if a paramedical practitioner is registered?
    You can start by asking your provider if they are registered. Following that, it’s a good idea to confirm that your provider is actively registered. For BC providers, you can do this online:
  32. Will PBC reimburse my EHC claim via direct deposit?
    PBC will reimburse EHC claims to a bank account of your choice if you have registered for direct deposit. You can register for both direct deposit and to receive electronic claim statements through CARESnet.
  33. Where do I go to get more information about my extended health coverage?
    We've made it easy and convenient for you to find out more information about your extended health benefits. There are multiple channels for you to obtain information:
    • CARESnet - 24 hour web access to your plan benefits and claim history information
    • Contact us by phone:
      Dental 604 419-2300
      EHC 604 419-2600
      Dental & EHC 1 888 275-4672 (toll-free)
    • or e-mail us

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