What Advisors Need to Know

1. What is covered under Plan NP?

   As of March 1, 2026, eligible diabetes and menopausal hormone therapies will be covered under Plan NP.
   Medication coverage began March 1, 2026.

   Some diabetes supplies and devices will be introduced on April 1, 2026, and are not included in the March 1 medication changes. Details about device coverage are not yet available from BC PharmaCare.

   The official list of eligible medications can be viewed on the BC PharmaCare website:

   • Diabetes
   • Menopausal Hormone Therapies 

   Eligibility 

   All BC residents enrolled in Medical Services Plan (MSP) are automatically eligible for Plan NP. No separate application is required. Coverage will begin from the first dollar spent; there is no deductible under Plan NP.

   Members residing outside BC are not eligible for Plan NP.

2. What this means for your plan

   Plan NP applies to a defined group of medications and does not change your overall plan structure.

   • BC PharmaCare may now act as the primary payer for certain medications
   • Pacific Blue Cross continues to coordinate coverage based on your plan design
   • There are no immediate changes to your plan design or premiums as a result of this update
3. What this means for your employees

   Most members will notice little or no change when filling prescriptions.

   • Fully covered medications are paid directly by BC PharmaCare
   • Partially covered medications may be supplemented by Pacific Blue Cross, depending on plan design
   • Special Authority requirements continue to apply for certain medications
4. How does Plan NP work?

   Fully covered medications

   For medications fully covered under Plan NP, BC PharmaCare will act as the primary payer. These claims will be processed through BC PharmaCare and will not be reimbursed through the Pacific Blue Cross plan.

   Partially covered medications

   For partially covered medications, BC PharmaCare will pay up to the cost of a generic alternative (Low-Cost Alternative rule). Depending on plan design, Pacific Blue Cross may reimburse part or all of the remaining eligible cost. Most partially covered medications are brand-name drugs that have generic alternatives. Where appropriate, dispensing a generic alternative may result in full coverage.

   Special Authority medications

   The following medications require Special Authority approval from BC PharmaCare before they are eligible for coverage under Plan NP:

   • Saxagliptin or Saxagliptin/Metformin (also know as Onglyza or Komboglyze)
   • Linagliptin or Linagliptin/Metformin (also know as Trajenta or Jentadueto)
   • Pioglitazone (also know as Actos)

   Existing Special Authority approvals will carry forward under Plan NP.

   Members currently taking these medications will not lose access. If Special Authority approval is not granted under Plan NP, Pacific Blue Cross will continue coverage under the existing plan for impacted members. New prescriptions must obtain Special Authority approval from BC PharmaCare before coverage can be considered.

5. How will members know if their drug is covered under Plan NP?

   Members can use the PBC Mobile app or the Member Profile to view real-time eligibility information. 

   For medications covered under Plan NP, members may see one of the following:

   Message 1

   Not Covered

   Message Returned:

   (None)

   What does this mean?

   This typically indicates the medication is fully covered under Plan NP and processed directly through BC PharmaCare.

   Message 2

   May Be Covered

   Message Returned:

   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.

   What does this mean?

   If a medication requires Special Authority under Plan NP, the member will see a message advising them to consult their prescriber. Once approved, the pharmacy will submit the required information with the claim.

   Advisors can reassure sponsors that medications fully covered under Plan NP will not appear as reimbursed through Pacific Blue Cross because BC PharmaCare is acting as the primary payer.

   Message 3

   Covered

   Message Returned:

   No message

   What does this mean?

   For partially covered medications, BC PharmaCare will pay up to the cost of a generic alternative (Low-Cost Alternative rule).1

   Depending on plan design, Pacific Blue Cross may reimburse part or all of the remaining eligible cost.

   Footnote 1: Unless there is an exceptional approval to pay up to the cost of brand, in which case the medication becomes fully covered under Plan NP and these claims will not be paid through the PBC plan.
6. What if a member is already taking a drug that requires Special Authority under Plan NP?

   Members who are currently taking a drug that requires Special Authority under Plan NP will not lose coverage of those drugs. We still recommend that members apply for coverage under Plan NP, but in the event that request is ultimately denied, members will not lose access to the drug they have been taking.

   Members who are taking a fully covered medication under Plan NP that does not require Special Authority will likely see no disruption in accessing their medications.

7. What does this mean for members who live outside BC?

   Members who reside outside of BC do not have access to Plan NP. Claims for these medications will continue to be adjudicated under the Pacific Blue Cross plan based on the drug’s status and plan design. Open benefit drugs will be covered as per plan design. For drugs which require Special Authority, we ask that prescribers complete a Drug Eligibility Inquiry form and submit to us for review. 

8. Does Plan NP replace private drug coverage?

   No. Plan NP applies to a defined list of medications. Extended health plans continue to provide coverage for many other prescription drugs and health services.

9. Should sponsors expect premium reductions?

   Plan NP does not automatically result in premium reductions. Drug costs fluctuate based on overall utilization, new therapies entering the market, generic introductions, and broader claims experience. Sponsors should continue to evaluate plan performance based on total plan utilization and experience.

10. How significant is the financial impact on plans?

    Plan NP applies to a defined subset of medications. The impact on individual plans will vary depending on utilization and plan design and represent one component of overall drug spend.

    Plan pricing reflects total claims experience across the full drug portfolio. No immediate premium adjustments are anticipated as a direct result of Plan NP implementation.