Understanding BC’s Fair PharmaCare Deductible System

BC’s Fair PharmaCare program is the province’s income-based drug coverage plan. In simple terms, the less your family’s adjusted net income is, the more assistance you get with prescription costs. Coverage is determined by annual deductibles (the amount you pay out-of-pocket each year before PharmaCare starts paying) and family maximums (the limit after which PharmaCare covers all eligible costs for the rest of the year)www2.gov.bc.ca. Here’s a quick breakdown:

• Lowest incomes (e.g., adjusted net family income below approximately $20,000) – No deductible; PharmaCare covers 100% of eligible prescription costs right away.

• Moderate incomes – A deductible applies, which is a percentage of your adjusted net family income. After this deductible, PharmaCare typically covers 70% of eligible costs (or 75% for families with a senior member born before 1940) until a family maximum is reached, then 100%.

• Higher incomes – A higher deductible (proportional to income) must be paid out-of-pocket before coverage kicks in. After the deductible, PharmaCare typically covers 70% of eligible drug expenses (or 75% for families with a senior member born before 1940) for the rest of the year (until the family maximum is met, after which it covers 100%).

The intent of this system is to protect families from catastrophic drug costs while asking those with higher incomes to contribute more. It works well for many: families with very low incomes pay nothing for eligible prescriptions, and those with very high incomes can generally afford their costs or have private insurance. However, many patients in the middle – not ultra-poor, but not wealthy – encounter serious challenges under this system.

Middle-Income Patients Caught in the Middle

For patients of modest or middle income, the annual deductible can be a significant hurdle. In Metro Vancouver (with its high cost of living), I’ve met patients who simply cannot afford to spend hundreds or thousands of dollars on medications early in the year, even though they would get coverage later in the year once their deductible is met.

Ironically, these are often working people or seniors on fixed pensions who don’t qualify for zero-deductible assistance but also don’t have the spare cash that higher-income families do.

To illustrate, consider a family with a combined income that gives them a $1,200 annual deductible. If their medication costs are about $200 a month, they will pay full price for roughly the first six months of the year (until they’ve paid $1,200) before PharmaCare coverage kicks in. During those first six months, this family gets no help at all, even though by year’s end they will have paid the same $1,200 out-of-pocket whether it was spread out or lumped at the start.

For a family living paycheque-to-paycheque, front-loading all their drug expenses in the first half of the year is a heavy burden – some end up delaying or forgoing medications in those early months simply because they can’t afford the upfront cost. In effect, the deductible system can be unfair to those with limited cash flow or savings, even if their total annual drug expense may be manageable over 12 months.

Not Filing Taxes – No Coverage

Another hidden issue is that PharmaCare eligibility relies on filing income taxes. The program checks your reported income (from two years prior) to set your deductible each year. If you haven’t filed a tax return, PharmaCare has no income info for you – meaning you may be treated as if you have the highest income. In fact, if income data isn’t available, PharmaCare assigns a default $10,000 deductible (essentially no effective coverage at all). Many vulnerable patients – for example, those who are homeless, dealing with mental health issues, or new immigrants unfamiliar with the system – do not file taxes and thus miss out on PharmaCare coverage they should be eligible for.

Even some low-income seniors fall through the cracks by not filing; as BC’s Seniors Advocate noted, it’s distressing that people with very low incomes are “forgoing hundreds or thousands of dollars in benefits that depend on filing tax returns” – and Fair PharmaCare is one of those key benefits.

What can be done? For patients in this situation, the first step is often help with filing taxes. There are community programs and free clinics that will do tax returns for low-income individuals at no charge. The Canada Revenue Agency’s Community Volunteer Income Tax Program operates free tax clinics across the country for those with modest incomes.

In BC, health authorities and non-profits regularly host such clinics – “There are free tax clinics that can help. Ask your patient to Google ‘free tax clinic’.” as one Vancouver Coastal Health guide advises doctors. Even the provincial government has a help line: the Ministry of Social Development and Poverty Reduction will assist people in getting ID and filing their taxes so they don’t miss out on benefit.

Crucially, if a patient was exempt from filing Canadian taxes (e.g., new resident, worked overseas, or a minor with no income), they can submit a Fair PharmaCare Proof of Income Affidavit to report their income directly to PharmaCare and establish their coverage.

Bottom line: filing that tax return or submitting an affidavit can open the door to PharmaCare coverage, and free help is available to do it if patients know where to look.

A Solution to the Deductible “Cash-Flow” Problem

If a family knows they’re likely to spend enough on prescriptions to meet their deductible each year, there is a little-known option that can prevent the mid-year coverage gap.

BC PharmaCare offers a Monthly Deductible Payment Option (MDPO). Under the MDPO, instead of paying your whole deductible out-of-pocket before getting coverage, you arrange to pay it in equal monthly installments throughout the year. As soon as you enroll in MDPO, PharmaCare acts as if you’ve met your deductible – meaning you get immediate coverage of eligible prescriptions right from January 1st. You then pay your portion at the pharmacy and also pay your fixed monthly payment toward the deductible to the government. By the end of the year, you will have paid the same amount, but your costs are spread evenly each month, which is much more manageable for people on a fixed budget.

For example, the family with the $1,200 deductible could enroll in MDPO and pay $100 per month. PharmaCare would start covering 70% of their prescription costs immediately, so they’d only pay 30% at the pharmacy all year. Note: the exact amount covered (e.g., 70%) depends on a family’s income level and PharmaCare’s coverage rules.

This does remove that six-month “no coverage” window and ensures they aren’t forced to delay treatments early in the year. It essentially turns a large yearly bill into a predictable monthly expense.

How to enroll: You must be registered for Fair PharmaCare and have a deductible greater than $0 to qualify.

It’s important to note that you cannot be enrolled in MDPO if you have private health insurance with a drug benefit plan, as this can complicate or delay your private health benefits if PharmaCare processes claims as primary payer.

To sign up, you fill out a one-page form (the MDPO 2025 Enrolment Form, code HLTH 5303) and mail or fax it to PharmaCare.

Note: If you plan to use the MDPO for the current year, you need to enroll by late September of that year to spread payments; otherwise you can enroll for the next calendar year. Once enrolled, your monthly payment can be set up as an automatic bank withdrawal or you can pay via monthly invoices. PharmaCare will provide tax receipts so you can claim the deductible payments as medical expenses on your income tax later.

The MDPO isn’t widely known, but it can be a lifesaver for middle-income patients who struggle with upfront medication costs. One of my aims in writing this is to raise awareness of this option – it makes the PharmaCare system a bit fairer for those who have the income “on paper” but not in their wallets on January 1st.

When Private Insurance Creates Additional Hurdles

It’s not only the uninsured or middle-class who have issues – paradoxically, even patients with private drug insurance plans can hit roadblocks to accessing medications.

Many extended health benefit plans in BC are designed to work in coordination with PharmaCare (often called a “PharmaCare tie-in”). In practice, this means if a prescription is expensive or falls under certain categories, your insurance will only cover it after you’ve gone through the PharmaCare approval process for that drug.

Typically, these are medications that PharmaCare covers only under special conditions – for example, expensive brand-name drugs or biologics that require a doctor to certify that certain criteria are met. Under a PharmaCare tie-in, the doctor must submit a “Special Authority” request to BC PharmaCare on the patient’s behalf, and only if PharmaCare grants approval (or at least acknowledges the request) will the private insurance plan pay its share.

The rationale is that this ensures the drug is being used appropriately and that the insurance isn’t paying for something the provincial plan would cover. From a system cost perspective it makes sense – but for patients and doctors, it’s yet another layer of bureaucracy.

The real-world impact: I’ve seen patients caught in limbo waiting weeks (sometimes months) for a Special Authority approval and processing of such approval.

Currently, the turnaround time for regular faxed Special Authority requests can be as long as 10 weeks, while eForms are generally quicker.

With the current doctor shortage, getting the forms filled out can be challenging – doctors are extremely busy, and paperwork may not be prioritized. Some physicians are even reluctant to complete the forms or charge the patient an extra fee to do so (since form-filling isn’t an insured service).

While physicians should generally not charge patients for Special Authority forms that are a prerequisite for PharmaCare coverage of eligible drugs, some clinics may charge an administrative fee for completing forms, particularly if requested by a third-party insurer.

From the patient’s perspective, this is a double barrier: a form that might be delayed or cost money to have completed. Meanwhile, the clock is ticking and the patient cannot get coverage for the medication until the paperwork goes through.

In many cases, people simply give up and don’t start a potentially beneficial drug therapy because the process is too onerous or they can’t afford to pay out-of-pocket during the delay. It’s a frustrating situation where having insurance doesn’t actually guarantee timely access to medication. What can be done here? For now, patients should know their rights: if a physician does charge a fee for a Special Authority form, many insurance plans will reimburse that fee as part of health benefits. (For example, Pacific Blue Cross explicitly advises that any fees for Special Authority forms “are covered, and should be submitted to PBC” for reimbursement.) That at least removes the financial sting of the form for the patient, though it requires the patient to pay upfront and navigate another claim.

A better solution would be system-level fixes:

• Streamline the Special Authority process.

  BC PharmaCare has moved some forms online (Special Authorit eForms are exceptionally faster), but more integration with doctors’ electronic medical records could help. If it was faster and easier for prescribers to complete these requests (or if certain criteria could be pre-approved), it would reduce delays.

  The province could also allocate more resources to process approvals faster – a few years ago when a large employee group was moved onto PharmaCare-linked coverage, Special Authority wait times ballooned to 2–3 months, a delay which is simply unacceptable when someone needs medication. Shortening that turnaround time is critical.

• Allow other healthcare professionals to assist.

  Pharmacists, for example, might be empowered to initiate Special Authority requests or help coordinate the paperwork, especially for straightforward cases. Some pharmacists already help by suggesting covered alternatives or generics to bypass the need for special approval. Expanding their role could take pressure off doctors and speed up patient access.

• Re-examine insurance policy.

  Do all these cases truly need prior PharmaCare approval? In some instances, the requirement could be waived if the patient’s physician provides direct justification to the insurer.

  Insurers could implement their own timely prior authorization review (many do for drugs that aren’t tied to PharmaCare) so that patients aren’t left waiting on a government process. Alternatively, insurers might offer interim coverage for a month or two of therapy while a PharmaCare decision is pending, so at least the patient isn’t without treatment.

• No patient left unsupported.

  As a policy goal, neither government nor insurers should design systems that leave a patient in the lurch. If we value public health, we should consider universal pharmacare or at least tighter coordination between public and private drug plans to eliminate these gaps.

  The federal Advisory Council on Pharmacare pointed out that one in five Canadians struggles to afford their prescriptions and many suffer worse health outcomes as a result.

  We can do better, even within our provincial program, to ensure that having insurance (public, private, or both) actually translates into getting your medications without undue hassle.

Moving Forward: Making PharmaCare Truly Fair

BC’s PharmaCare system has laudable aims and does help thousands of families afford life-saving drugs. But as I’ve outlined, there are several gaps that hit hardest on those in the middle – people with limited cash flow, or those facing bureaucratic obstacles. From the patient who didn’t file a tax return and unknowingly misses out on coverage, to the senior who can’t afford their pills until mid-year when their deductible is finally met, to the individual whose insurance insists on an approval that’s stuck on a doctor’s crowded to-do list – these are all fixable problems. What are the solutions? On a practical level, we should:

• Connect patients with tools and supports (like free tax clinics, the Proof of Income Affidavit, and the MDPO payment plan) so they can access the benefits already in place.

• Increase awareness among both the public and healthcare providers about these issues – many patients don’t know why they suddenly have a $10,000 deductible or that they could spread their payments monthly; many doctors may not realize the financial strain their patients are under early in the year or the importance of that Special Authority form.

• Advocate for policy changes: for example, consider automatically enrolling all residents in PharmaCare when they get their BC Services Card/MSP by facilitating consent for income verification, so no one is unknowingly uncovered. The government could also consider lowering deductibles or co-pays for middle-income brackets to lessen the upfront burden (even if it means slightly higher co-insurance later in the year). And as discussed, streamlining the special approval process or coordinating it better with private insurers would remove a needless barrier to care.

As a doctor, I hate to see a patient’s health suffer because of an inability to pay for or navigate the system for their prescriptions. Medications only work if you can actually get them. BC has a strong foundation with PharmaCare, but by addressing these gaps – making sure everyone files their taxes or provides income proof, smoothing out deductibles over the year, cutting red tape between insurers and PharmaCare – we can ensure that “PharmaCare” truly provides care, and not just in name. It’s about fairness and compassion: no patient should have to choose between paying the rent and taking the medication that keeps them healthy.

Sources:

• BC Ministry of Health – Fair PharmaCare coverage and deductibles

• BC Ministry of Health – Tax filing requirements for PharmaCare

• BC Ministry of Health – Fair PharmaCare Proof of Income Affidavit

• Vancouver Coastal Health – Guide for physicians on helping patients afford meds

• BC Ministry of Health – Monthly Deductible Payment Option (MDPO) details

• BC Ministry of Health – MDPO 2025 enrolment form

• Pacific Blue Cross – Prior authorization and PharmaCare Special Authority (and relevant FAQs about fee reimbursement)

• BC Ministry of Health – Special Authority (SA) Turnaround Times

• Canada Revenue Agency – Community Volunteer Income Tax Program