Pacific Blue Cross drug coverage explained
Tuesday, Dec 9, 2025Your Pacific Blue Cross plan covers a wide range of drugs; however, there are a number of a factors that may impact how your drug claim is reimbursed.
Your Pacific Blue Cross plan covers a wide range of drugs; however, there are a number of a factors that may impact how your drug claim is reimbursed. Below is some important information you need to know before you submit a drug claim to Pacific Blue Cross, to understand how your claims may be reimbursed.
Contents
- Pacific Blue Cross prior authorization (or pre-approval)
- BC Fair PharmaCare and Special Authority
- Understanding reimbursement and generic drugs
- Troubleshooting coverage issues
- Understanding Explanation of Benefit (EOB) messages
Pacific Blue Cross prior authorization (or pre-approval)
Some medications are only covered if they are prescribed for certain uses. You may be required to obtain prior authorization (also known as pre-approval) before a drug may be covered under your plan. Continue reading to find out how to check your coverage and submit a request for pre-approval.
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How do I check if pre-approval is required before a drug is prescribed to me?
It’s best to check whether a drug requires pre-approval while you’re speaking with your prescriber during your health appointment. You can obtain real-time coverage information using the Drug Look-Up tool in your Member Profile, which you can access on the Pacific Blue Cross mobile app, or through your web browser. If this is your first time logging in to your Member Profile, you can watch our video tutorial to help you get started.
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How do I check my drug coverage?
It’s easy to check the details of your plan in your Member Profile.
On your web browser
Log in at pac.bluecross.ca/Member, then head to the Your Coverage section, and select View Details under the Drug tab. Type the drug name or Drug Identification Number (DIN) into the search bar to find the drug that you have been prescribed. Check that the drug strength and dosage form listed match your prescription, then click View.
In the app
Open the app and log in. Go to My Benefits, then select Drug from the row of icons at the bottom of the screen. Type the drug name or Drug Identification Number (DIN) into the search bar to find the drug that you have been prescribed. The same drug name may be listed multiple times – select each one to find the drug strength and dosage form that match your prescription.
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What do the different coverage messages in Member Profile mean?
When you look up a drug in Member Profile, you will receive one of the following messages:
IF YOUR DRUG IS… THEN… Covered This drug is eligible for reimbursement without the need for pre-approval and can be claimed immediately.
Please note that policy rules and limits still apply, including but not limited to maximum days’ supply and reimbursement percentage.
May Be Covered This message usually indicates that some form of pre-approval is required. The section below identifies the next steps depending on the information provided in Member Profile.
Not Covered The drug is not eligible for reimbursement under your policy. There may be alternative drug therapies that are covered. Speak with your prescriber to determine if an alternative therapy may be right for you.
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What should I do if my drug “May Be Covered”?
If your search through Member Profile returns “may be covered”, your next steps vary depending on which message you receive.
IF THE RETURNED MESSAGE SAYS… YOUR NEXT STEPS ARE… This drug may be eligible under PharmaCare’s Special Authority Program. Please consult with your doctor or nurse practitioner who may apply on your behalf. If your application is approved, your pharmacist will submit the required information with your claim.
Have your prescriber submit a Special Authority Request to PharmaCare on your behalf. They will be familiar with this process. Once approved, your future claims for this drug will automatically be eligible for reimbursement.
This drug may be eligible through Pacific Blue Cross Prior Authorization Program. Please visit our website for the form and have your doctor apply on your behalf. We will review and advise on eligibility for this drug.
Have your prescriber complete and submit the relevant Pacific Blue Cross Prior Authorization form for us to review.
You submitted a drug that may be covered by a government agency. Please speak with your doctor who may apply on your behalf. If government agency funding is not available in your province, please have your doctor submit a Drug Eligibility Inquiry (DEI) form. We will review on a case-by-case basis and advise on the eligibility for this drug.
These medications are not typically covered because they are provided by provincial health care programs at no cost.
BC Fair PharmaCare
BC PharmaCare is a publicly funded drug program that helps British Columbians with the cost of eligible prescription drugs and medical supplies. PharmaCare’s drug review process and listing decisions are evidence-based, which ensures only drugs that are safe and cost-effective are listed.
A family will initially pay 100% of the medication costs until the annual deductible is met. 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, which is the total amount a family can spend on eligible drugs before Pharmacare will start covering 100% of the costs. This is to protect families against very high medical expenses. Your family maximum will also be determined by your income.
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.
PharmaCare’s Special Authority program grants full or partial coverage to a drug that otherwise would not be covered or covered only partially. This coverage is provided to patients in specific medical circumstances.
We work to align our drug policies with PharmaCare so that we make the best use of public drug coverage. This helps manage rising drug costs, keep our plans affordable, and prevent members from hitting their coverage limits.
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How do I register with PharmaCare?
Members who have not yet registered with PharmaCare will be able to receive reimbursement for eligible drugs until the annual total reaches $1,750 in a 12-month period. At that time coverage will be temporarily halted until you provide proof of registration with Fair PharmaCare. Please note that this annual maximum may differ between policies.
To avoid potential disruptions to your coverage, we recommend that you register with PharmaCare as soon as possible.
Register for PharmaCare online 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
After you register, you can print the screen confirming that your application has been submitted. PharmaCare will also send you a confirmation letter.
Once you reach the $1,750 limit, Pacific Blue Cross will send you a Declaration of Fair Pharmacare Registration form in the mail. You will need to complete this and return it to us, following the instructions on the form. This will allow us to verify your Fair PharmaCare registration status; once we have done so, your coverage will resume.
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Why should I apply for PharmaCare Special Authority, even if I have Pacific Blue Cross drug coverage?
Where possible, Pacific Blue Cross has aligned coverage with BC PharmaCare so that our members can take advantage of public funding for eligible drugs. This helps drugs plan to remain sustainable for our plan sponsors and members well into the future.
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How do I apply for PharmaCare Special Authority?
Have your prescriber submit a Special Authority Request to PharmaCare on your behalf. They will be familiar with this process. Once approved, your future claims for this drug will automatically be eligible for reimbursement.
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How can I find out if my Special Authority request has been approved by PharmaCare?
There are several ways to check the status of your Special Authority application with PharmaCare.
The BC Health Gateway: This service was introduced by the BC Ministry of Health in 2024 and is the easiest way to find the most up-to-date information regarding your application.
- Visit healthgateway.gov.bc.ca and set up or log in to your account.
- Select Health Records from the list of options.
- Select Special Authority under the list of categories.
You will be able to see the current status of your application if it has been received or processed by PharmaCare.
PharmaCare response letter: Whether your request is approved or denied, PharmaCare will send you a written response in the mail.
Ask your pharmacy team: You can ask your pharmacy team to do a test claim on your behalf. This is a frequent standard of practice and can be done at no cost to you. Please note: the pharmacy will only be able to tell you if your request was approved and the expiry date if it is active. They will not be able to determine if a submitted request was rejected.
Ask your prescriber: Your prescriber will also receive a fax response from PharmaCare, indicating their decision.
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Do I need to submit a copy of my Special Authority approval to Pacific Blue Cross?
For the majority of eligible medications, our system can read the approval codes from PharmaCare and approve your claim automatically. Unless you are experiencing difficulty having your claims approved, you do not need to submit a copy of your Special Authority approval letter to us. However, please keep a copy of the letter in a safe place in case you do need to submit it.
Proof of PharmaCare Special Authority can be any of the following:
- A copy of the Special Authority Approval letter mailed to you by PharmaCare.
- A copy of the response from PharmaCare that was faxed or mailed back to your prescriber.
- A screenshot from your BC Health Gateway account that includes the expiry date (if applicable) of your Special Authority.
- A copy of your official prescription receipt that includes a “BCSA1000” or “BCSA1100” code issued by PharmaCare.
Understanding reimbursement and generic drugs
Where drug brand patents have expired, equivalent generic versions are sometimes available. Many Pacific Blue Cross plans limit drug reimbursement to the cost of an eligible generic alternative. If you notice that your claims are being reduced at a rate that is less than what you are expecting, it may be the case that a generic version is available and that your reimbursement is limited to the cost of this alternative. You can ask your pharmacist whether you are receiving the generic or brand name product, and check your drug coverage in Member Profile to see whether brand name or generic versions are covered under your plan
Generic drugs have been approved by Health Canada based on the fact that they are equally as safe and effective as brand name drugs, but available for a fraction of the cost. These savings contribute to the overall sustainability and affordability of your policy.
Here are some examples that detail the difference in price between brand name and generic drugs:
It is important to note that Pacific Blue Cross does not notify members before a new generic product is made available under your extended healthcare plan. In most cases, reimbursement will be reduced to the cost of the generic product as soon as it is available. Read below for more information and advice on this.
Troubleshooting coverage issues
Are your claims not being approved in the way you expect? Here are some common situations and resolutions that may help.
| IF THE DRUG IS… | AND… | THE ISSUE IS LIKELY |
|---|---|---|
| Covered |
The reimbursement amount is lower than expected |
Check with your pharmacist… If a generic alternative is available, your policy will likely only provide reimbursement for the cost of the generic. See the next section for more details. |
| Covered |
The reimbursement amount is lower than last time. |
Check with your pharmacist… Is there a new generic alternative? Your policy will likely reduce reimbursement to the cost of the generic as soon as it is added to our list of covered drugs. It is highly recommended that you investigate any reimbursement issues before you leave the pharmacy. Once a medication leaves the pharmacy, by law, it cannot be returned. If a generic alternative could have been dispensed, Pacific Blue Cross will likely not consider reimbursing a brand-name drug product. |
In many cases, your pharmacy team may call us on your behalf to investigate issues with coverage. Otherwise, if none of the examples above apply to you, or you still need assistance, please reach out to our Customer Service Team who will be happy to assist you.
Understanding Explanation of Benefit (EOB) messages
Once your claim has been approved or denied, it may be accompanied by a message from us that relays important information about how your claim was processed. Sometimes, this message will include instructions you will need to follow to ensure future claims are adjudicated correctly. Here are some examples:
| IF THE MESSAGE SAYS… | THEN |
|---|---|
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Eligible Amount reduced due to eligible dollar pricing rule. |
The reimbursement amount of your claim has been reduced. This happens when you submit a claim for a brand name drug where there are generic alternatives available. |
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We have considered the drug cost portion up to the appropriate dosing daily price of $12.345 under the plan. *Price listed is for example only |
The submitted drug is covered only up to a specific dose. In most situations, that would be the Health Canada approved maximum dose. If you are claiming this drug at a dose that is higher than what is eligible, then reimbursement will be reduced to the eligible dose. |
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Based on the information in your file, we are your primary Insurer for this expense, but your other Insurer paid first. To ensure there is no overpayment, we will pay as secondary. In future, please submit your expenses to us first. If there has been a change in your coverage status, please send us the information so we can update your file. |
Many Pacific Blue Cross members have more than one extended healthcare plan, often through a spouse or parent. If you have multiple extended healthcare policies, please make sure you are submitting claims to your own policy first. |
Call us at 604 419-2000 (Lower Mainland)
Toll-free in BC at 1 877 722-2583
Monday to Friday 8am to 4:30pm PT (excluding statutory holidays)