| This section of the website provides information on
how to make a claim under the various benefit plans. Please click on one of the benefit plans
below to link to the information.
For pharmacies on line with Pacific Blue Cross, the pharmacist is able to
determine at the time you purchase your prescription, the amount that our drug plan will
reimburse. The drug plan will reimburse this amount directly to the pharmacy — you will
only pay your portion. If your Pharmacare deductible has been reached, the Pharmacare portion
will also be paid directly to the pharmacy.
There is an annual deductible of $35.00
(Effective Jan. 01, 2007 — $45; Effective Jan. 01, 2008 8212; $55; Effective Jan. 01,
2009 — $65) in any one calendar year from the eligible expenses of either a single
person or a family. However, if your total expenses for the calendar year do not exceed the
deductible, expenses incurred in the last three months of the calendar year can be applied
against the deductible the following year.
The plan reimburses up to $100,000
within a lifetime, for any one employee or any one dependent.
This lifetime maximum may be reinstated, after paying for any one serious
illness on the basis of satisfactory evidence provided by the employee to the carrier of
complete recovery and return to good health.
If your expenses exceed the annual deductible, you may claim for a reimbursement of your
remaining expenses as follows:
80 per cent of eligible in-province expenses until $1,000 of benefits
have been paid in a calendar year; and 100 per cent of eligible in-province expenses over $1,000 in a calendar
year; and 100 per cent of eligible out-of-province/out-of-country emergency
expenses in any calendar year.
Example:
| Eligible Receipts = |
$135 |
| Less Annual Deductible = |
- $35 |
| Subtotal = |
$100 |
| Reimbursement (80 per cent of $100) = |
$80 |
When submitting a claim, be sure to keep a copy of your receipts for your records.
CLAIMS FOR SERVICES RECEIVED IN THE PREVIOUS CALENDER YEAR MUST BE IN THE OFFICE OF THE
CARRIER BY JUNE 30TH. LATE SUBMISSIONS WILL NOT BE PAID. IT IS
RECOMMENDED THAT CLAIMS BE MADE ON AN ONGOING BASIS TO PREVENT LATE SUBMISSIONS.
The annual deductible does not apply to:
- eyeglasses or contact lenses
- hearing aids
- needleless insulin injectors
Example:
| Eligible eyewear receipt = |
$200 |
| Deductible does not apply = |
0 |
| Subtotal = |
$200 |
| Reimbursement ($200 maximum) = |
$200 |
If your expense is less than the maximum allowable, you will receive the full amount of
that claim.
If your pharmacy charges a dispensing and/or prescription fee in excess of
the plan coverage, your reimbursement will be limited to the dispensing and/or drug fee provided
under the plan. In this situation you may wish to consider changing pharmacies or using the
services of a mail order pharmacy which will deliver directly to your home or office.
Please note that for those pharmacies not on line with Pacific Blue Cross,
you pay the full amount and submit receipts for reimbursement.
If you have coverage under two different drug plans, you cannot use the online
services with Pacific Blue Cross. You must pay the costs and submit your receipts for
reimbursement to both plans. As your original receipts will not be returned, please make a copy
to send to your second carrier.
An Extended Health Benefits Claim form is accessible from the
BC Public Service Agency Forms Page
and is also available from your personnel or payroll office.
Pacific Blue Cross now offers CARESnet, an on-line system that allows you the ability
to track recent extended health claims that you have made through Pacific Blue Cross, along with
your claims history. To access CARESnet contact the Pacific
Blue Cross web site to register.
The extended health plan reimburses 80% of your eligible expenses after you have satisfied
your $35 (Effective Jan. 01, 2007 — $45; Effective Jan. 01, 2008
— $55; Effective Jan. 01, 2009 — $65) deductible. Once you reach your Pharmacare
deductible, Pharmacare reimburses 70 percent of eligible expenses over the annual deductible
amount and the extended health plan reimburses 80% of the cost not reimbursed by Pharmacare.
Your Pharmacare annual deductible is based on your family income. If your annual expenses
exceed your annual Pharmacare deductible and you have registered for Pharmacare, Pharmacare’s
portion of the purchase will be paid directly to the pharmacy.
Pharmacare sets an annual maximum under its plan based on your family income. Once your
eligible expenses reach this maximum, Pharmacare pays 100% of your family’s further eligible
expenses for the remainder of the year.
To be eligible to receive the maximum benefit under the plan, you must register with
Pharmacare. For information on Pharmacare, visit their website at:
http://www.health.gov.bc.ca/pharmacare/
If you wish to determine your Pharmacare deductible, please use the Fair PharmaCare Calculator
on the Pharmacare website.
Example: (Based on a family income of $50,000)
| Eligible receipts = |
$2,000.00 |
| Less current Pharmacare deductible = (based on a family
income of $50,000). |
-1,500.00 |
| Subtotal payable by Pharmacare = |
$500.00 |
Pharmacare reimbursement =
(70 per cent of $500.) |
$350.00 |
The Extended Health Plan reimburses 80 per cent of eligible expenses not reimbursed by
Pharmacare.
Example:
| Eligible receipts = |
$2,000.00 |
| Less Pharmacare reimbursement = |
-350.00 |
| Subtotal = |
$1,650.00 |
| Less Extended Health deductible = |
-35.00 |
| Subtotal = |
$1,615.00 |
| Reimbursement (80 per cent of $1,250.00) = |
$1,000.00 |
| Extended health reimbursement after
$1,000. (100% of $370.00 = ) |
$365.00 |
| Total Extended health plan reimbursement |
$1,365.00 |
| Total |
$1,715.00 |
In this example the total receipts were $2,000.00 and the amount reimbursed was $1,365.00
plus Pharmacare reimbursement of $350.00. The employee cost was $2,000.- $1,715.00 = $285.00
REMEMBER TO:
Keep all receipts and submit regularly. Submit all receipts to Pacific Blue Cross. Submit claims for services
received in the previous year no later than June 30. Claims received in the office of the
Carrier after June 30 will not be paid. Keep photocopies of your receipts. (Your original receipts will not be
returned.)
Generally, the dentist will complete the claim form on your behalf and submit the claim
directly to the carrier. You will need to provide the dentist with your group number, and
your identity number from your dental identification card. After accepting and paying the
claim, the dentist will send you an itemized statement of the portion of the expenses not
covered by the plan.
If you pay the dentist directly for the cost of their services, ask the dentist to submit the
claim on your behalf indicating on the form the claim should be paid directly to the member.
Please ensure the dentist provides your current address on the dental claim form.
All dental claims must be submitted within one year of the date of service. Claims received
later than 12 months from the date of service will not be paid.
For Claim information, please contact Pacific Blue
Cross.
Orthodontic Claims
To claim orthodontic benefits, you must send the carrier:
· A treatment plan (completed by the dentist) before treatment starts
· Photocopies of receipts monthly, as treatment progresses. (Receipts are not to be held
until completion of treatment)
Payment of orthodontic claims will be pro-rated over the months of the treatment. Monthly
payments are made until the dollar maximum is reached or the treatment is completed,
whichever occurs first. If you pay the full amount to the dentist in advance of completed
treatment, your payment will be pro-rated over the months of the treatment period, provided
your coverage remains in effect.
All orthodontic claims must be submitted within one year of the date of the monthly receipt.
View your extended health and dental claims online
Pacific Blue Cross now offers CARESnet, an on-line system, providing self-service
access to view your extended health and dental claims information. This service is available
to all employees enrolled in the extended health and dental plan. To access CARESnet visit the
Pacific Blue Cross web site to register. There you
will find an on-line tour of CARESnet and links to the CARESnet registration and sign in.
(CARESnet requires an easy one-time registration to establish a secure connection to your
information).
You may arrange to have extended health and dental claim reimbursements deposited directly
into your bank account. The enrolment form for this service can be downloaded from the CARESnet
section of Pacific Blue Cross' website.
Most physicians in other Canadian provinces and territories (except Quebec) will bill their
own medical plan directly for services provided to you, if you present your valid BC Care Card.
When travelling in Quebec or outside Canada, you will be required to pay for insured services
and seek reimbursement later from MSP. These claims must be submitted within six months of the
date of service.
For complete protection during a vacation, additional medical insurance should be purchased
from a private insurance company.
see Extended Health (Coverage While Travelling
Outside of Canada) in this Guide.
Group Life Insurance Claims include:
- Life Insurance
- Accidental Dismemberment and Loss of sight
- Terminally ill Advance
- Burial Advance
- Optional Spouse and Dependent Claim
To initiate a claim or for assistance, please contact the Benefits
Service Centre
To initiate a claim or for assistance, please contact the Benefits
Service Centre
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