FAQ

1. What is a Pharmacare eligible drug?

The Pharmacare drug benefits list is divided into three parts. Part I includes Prescription drug products that are eligible for Pharmacare benefits under all prescribed circumstances.

Part II includes drug products that are eligible for Pharmacare benefits only when prescribed for the terms and conditions indicated. Doctor's only have to indicate "Meets EDS" on the prescription for Part II status.

When a drug is not listed in Part I or part II, a request for Exception Drug Status coverage will be considered under Part III for each individual's specific circumstance. Your doctor can apply to the Pharmacare Exception Drug Status program, at 300 Carlton Street, Winnipeg, Manitoba R3B 3M9.

Under this program physicians are able to apply to obtain drug coverage (for each person) for medication not normally covered. The approval is generally given for a one-year period, (some are now being changed to a three-year period) after which time the person's doctor must reapply. A one-time notification indicating drug coverage dates are sent to individuals at time of approval.

2. What is Part II Exception drug status (EDS)?

Certain drugs are approved for coverage under the Exception Drug Status (EDS) Program when they are prescribed for a specific criteria as listed in the specified drug regulation. The physician must indicate "meets eds" on the prescription for Part II status.

3. What is Part III Exception drug status (EDS)?

Certain drugs are approved for coverage under the Exception Drug Status (EDS) Program when they meet specific criteria and upon review and recommendation of the Manitoba Drug Standards and Therapeutics Committee (MDSTC). The drugs usually fall into one of the following categories:

• The drug is ordinarily administered only to hospital in-patients but is being administered outside of a hospital because of unusual circumstances.
• The drug is not ordinarily prescribed or administered in Manitoba, but is being prescribed because it is required in the diagnosis or treatment of an illness, disability, or condition rarely found in Manitoba.
• Evidence, including therapeutic and economic evidence, provided to the minister in accordance with the criteria established by him or her, supports a specific treatment regime which includes use of the drug or other item.

Over-the-counter (OTC) products are generally not included as benefits of the Drug Plan. Exception Drug Status is not granted for appetite suppressants, smoking cessation products, drugs for the treatment of erectile dysfunction and vaccines normally provided by Public Health. When an EDS drug is approved as a benefit, the cost will be covered through the Pharmacare Program during the time period authorized by the EDS Program and after the clients Pharmacare deductible is met.

Physicians, dentists, or other professionals authorized by physicians may apply for EDS.

• Requests can be submitted by telephone, by mail or by fax. A toll-free line with an electronic message system is available exclusively for requests on a 24-hour basis
• To ensure eligible benefit coverage, approval must take place prior to purchase or dispensing of a prescription drug. Retroactive coverage is not provided.
• EDS requests are prioritized by date received and the urgency of the request.
• To ensure continuity of coverage, requests for renewal should be forwarded prior to the expiry date.

Please allow at least two weeks for processing.

• Patients are notified by letter if a request for coverage has been approved or denied.
• If a drug is approved for coverage under EDS, coverage is valid from the date of application to date of expiration.
• If denied, payment for the medication is the responsibility of the patient.

NOTE: Not all medications currently available on the market in Canada are benefits under the Manitoba Drug Benefits Formulary or under the EDS Program.

4. If I pay up front for my claim, can I be reimbursed directly into my bank account?

You can apply to have your claim payments deposited directly into your bank account. You can do this by registering for Customer E-Service and signing up for Direct Deposit.

5. Can I see my claims online?

Once you have registered for Customer E-Service, you will have access to your current claims history. Through this electronic service, you can gain quick access to your plan information, and benefit details.

6. What is Blue Advantage?

Blue Advantage helps Blue Cross members take advantage of cost savings on medical, vision and healthcare purchases offered by participating providers across Canada. Simply present your Blue Cross identification card to the provider to receive the savings!

7. If I have a complaint with regard to Life and Disability insurance products, what can I do?

If you are dissatisfied with a decision or service related to a life or disability insurance product, you can have the situation reviewed. For complaints dealing with the denial of a life or disability claim, please contact the case manager that handled your claim who will guide you through the appeal process for denied claims. For all other types of complaints related to life or disability insurance products, please follow the steps listed below:

1. Discuss your concern with the person or office that sold the product or provided the service. Many issues can be resolved by simply speaking with your advisor or a customer service representative. If you remain dissatisfied, please contact the Regional Compliance Representative at:

   Regional Compliance Representative

   Manitoba Blue Cross

   599 Empress St

   Winnipeg, MB R3G 3P3

   Fax: 204.788.5592

   Email : mbcompliance@mb.bluecross.ca

2. The Regional Compliance Representative will arrange to have your complaint investigated by a review committee. A second level of appeal is available to you if you are not satisfied with the review committee's determination.

3. If you continue to remain dissatisfied after following the Company's internal complaint handling process and wish to pursue your complaint, you may contact the OmbudService for Life & Health Insurance (OLHI).

   OmbudService for Life & Health Insurance (OLHI)

   401 Bay Street, Suite 1507

   P.O. Box 7

   Toronto, ON, M5H 2Y4

   Toll free: 1.888.295.8112

   Fax: 416.777.9750

   Email: information@olhi.ca

At all times throughout the complaint handling process, you may contact the Company's Complaints Officer for any questions or comments related to this process.

Federal Consumer Provision Complaints

The Financial Consumer Agency of Canada (FCAC) oversees compliance with federal consumer protection requirements. These requirements include providing consumers with information on complaint handling procedures and on borrowing costs. If you have a complaint about a consumer provision, you can contact the FCAC at: