FINAL REMINDER: Feb 27th deadline to file individual grievances related to Pharmacare tie-in
All BCNU members are reminded that February 27th is the deadline to file an individual grievance related to their lost drug coverage following the implementation of the Pharmacare tie-in.
What happened as a result of the "Tie-in"?
Our drug plan is linked to the province's Pharmacare listing of covered drugs, also known as a "formulary".
- If the drug you were taking prior to June 2013 was listed on the provincial Pharmacare formulary, the plan covers the drug. If it was not listed on Pharmacare or available via Pharmacare Special Authority, then the drug is not covered under the plan.
- As a result of an arbitration issued on December 1, 2013, some drugs that are not otherwise covered under the Tie-in will be grandparented (see below) or available on a case by case basis.
Under the arbitration award, there will be two different ways that additional drugs may be covered. These are described in the award as Appendix A and Appendix B, explained below.
Appendix A
Appendix A will include certain drugs not covered by Pharmacare that will be "grandparented". Based on preliminary data, the following drugs are being considered for full grandparenting: Xolair, Lyrica, Cymbalta, Victoza and Singulair. We expect to finalize Appendix A and make it available to members by May 2014.
What is Grandparenting?
- Grandparenting is an insurance concept that means that the old rules will apply for a specific period of time. In this case, drugs that are grandparented will be grandparented indefinitely for individual members, meaning that members will continue to have coverage for that drug for as long as they need it.
- Keep in mind that the grandparenting rule applies only if you had an approved claim for a drug between December 1, 2012 and May 2013. If you were prescribed a grandparented drug after May 2013, the drug will not be covered by the plan.
Appendix B
Appendix B includes funding for individual cases, according to a set of criteria.
What are the criteria for the individual cases?
You have until February 27, 2014 to submit a grievance for coverage for the drug you were taking prior to June 2013.
The following criteria will determine whether and how much coverage you will receive:
| Criteria | Why this matters |
|---|---|
| Complexity of your medical condition | Some medical conditions - such as high cholesterol - are reasonably common and may be treated by one of many different medications. Other medical conditions - such as multiple myeloma - are complex and may be treated by one or two specialized drugs. Depending on the medical condition, it may be very important to keep a plan member stabilized on a particular medication. |
| Length that you have been taking the drug | We take into consideration whether a plan member has been stabilized for many years on a particular drug. |
| Response to drug (input from your physician) | We want to confirm that you are actually benefiting (from a clinical perspective) from the requested drug. |
| Appropriateness of alternative drug on BC PharmaCare Formulary | Based on the advice of our external experts, some PharmaCare drugs are deemed appropriate alternatives, while other PharmaCare alternatives are less appropriate. This would be taken into consideration. |
| Potential impact of moving to alternative drug | There may be some cases where there may be concern that switching a member to an alternate drug could exacerbate their health issues resulting in a significant worsening of their condition. This would be taken into account. |
| Availability of alternative coverage | If you have coverage under another plan eg: your spouse's plan this will be considered. |
| Availability of drugs by Special Authority. | In order to be considered for coverage for a drug available through the PharmaCare Special Authority process the following criteria must be met:
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