Getting my medicine paid for

Authority Health Insurance BC - Pharmacare, Ministry of Health
Details

Elena required injections of medication in order to treat her medical condition. Those injections had to be given by her doctor at the doctor’s office. The doctor dispensed the medication directly. Elena paid her doctor and received a receipt for the medication which she submitted to PharmaCare for reimbursement. However, PharmaCare said it would not provide coverage for the cost of the medication because it was purchased directly from the doctor. Elena believed it was unfair to penalize her simply because she did not purchase the medication from a pharmacy. We investigated whether PharmaCare had provided Elena with adequate reasons for its decision to deny her coverage for the medication. PharmaCare explained that its policy is to only cover billings from a pharmacy or supplier that has signed a Pharmacy Participation Agreement with PharmaCare. Under this policy, PharmaCare will accept manual claims only from doctors who have signed such an agreement. Elena’s doctor had not signed such an agreement with PharmaCare.

As PharmaCare had not provided information about the policy to Elena directly, it agreed to adjudicate Elena’s claim on an exceptional basis. PharmaCare also explained Elena’s options for ensuring she received coverage in the future.

Category Health
Type Case Summary
Fiscal Year 2012
Location The Lower Mainland