Frequency of Dispensing and Payment Policy

The Frequency of Dispensing and Payment Policy establishes criteria for payment of dispensing fees for drugs taken continuously (long-term).

This policy applies to all individuals enrolled in the NB Drug Plans, which includes the New Brunswick Prescription Drug Program (NBPDP), New Brunswick Drug Plan (Plan D), Extra-Mural Program (Plan W), and Tuberculosis (TB) Drug Plan (Plan P). 

This policy applies to all claims for drugs in solid oral dosage form taken on a continuous basis. Continuous drugs are defined as those taken to treat long-term conditions such as high cholesterol, high blood pressure, or diabetes. Drugs used for the treatment of opioid use disorder which are subject to dispensing requirements outlined in the New Brunswick College of Pharmacists Opioid Agonist Treatment Practice Directive are excluded from this policy (e.g., buprenorphine/naloxone, slow-release oral morphine).

How often a prescription is dispensed is determined by the pharmacist in collaboration with the patient and other health-care providers involved in the patient’s care. Drugs taken continuously should be dispensed in a days’ supply which is appropriate for the product and the patient, up to 100 days at a time.

Purpose of Policy

This policy limits the payment of dispensing fees for drugs dispensed more frequently than every 28 days. If the criteria for payment of a dispensing fee under the policy are not met, pharmacies are only eligible for partial dispensing fees (no more than one dispensing fee every 28 days).

Pharmacies are eligible for one dispensing fee per claim for drugs dispensed in a 28 to 100 days’ supply. For most patients, drugs taken continuously can be dispensed in a 100 days’ supply.

Dosage changes: Pharmacies are eligible for 2 dispensing fees in 28 days if the claim for the new dose of an existing drug is within 28 days of the previous claim.

Schedule changes: Pharmacies may bill claims earlier than required to accommodate statutory holidays, patient vacations or other scheduling issues. However, over an 84-day period, pharmacies are only eligible for three dispensing fees for drugs taken continuously.

Individuals living in facilities - includes nursing homes, licensed adult residential facilities, and correctional facilities

Except for new drug starts and dosage changes, pharmacies that dispense drugs on a weekly, bi-weekly, or another schedule are only eligible for partial dispensing fees (see the Claim Submission section below.) Pharmacies are not eligible for additional dispensing fees regardless of whether daily, weekly or other more frequent dispensing was prescribed or requested.

Pharmacies are eligible for 2 dispensing fees in 28 days in the following instances:

• New drug* starts: if the initial claim is for less than a 28 days’ supply and a subsequent claim for the same drug is dispensed within the first 28 days.
•  Dosage changes: if the claim for the new dose of an existing drug is within 28 days of the previous claim.

* New drugs are those which have not been taken in the last 12 months. The adjudication system does not generate an electronic message to pharmacies if the patient has had the drug in the last 12 months. Pharmacists must confirm if the patient has taken the drug in the last 12 months.

Individuals not living in facilities

Pharmacies are eligible for 2 dispensing fees in 28 days in the following instances:

• New drug* starts: if the initial claim is for less than a 28 days’ supply and a subsequent claim for the same drug is dispensed within the first 28 days.
• Dosage changes: if the claim for the new dose of an existing drug is within 28 days of the previous claim.

* New drugs are those which have not been taken in the last 12 months. The adjudication system does not generate an electronic message to pharmacies if the patient has had the drug in the last 12 months. Pharmacists must confirm if the patient has taken the drug in the last 12 months

Pharmacies may bill partial dispensing fees for patients who receive more frequent dispensing without any special documentation (e.g., ¼ fee every 7 days.) See the Claim Submission section below.

For pharmacies to be eligible for more than one dispensing fee every 28 days, specific criteria must be met, and documentation is required as outlined below:

a)  Dispensing fee for drugs dispensed in a 7 to 27 days’ supply:

The patient’s drug therapy cannot be managed when dispensed as a 28-day supply and at least one of the following patient factors must apply:

• Risk of drug misuse, abuse, or diversion
• Failed to comply with a drug regimen dispensed in a 28-day compliance package due to cognitive impairment, mental disability, psychiatric illness or physical disability
• No fixed address and are susceptible to theft or loss of belongings
• Requires frequent laboratory tests for therapeutic drug monitoring (e.g., clozapine)

Pharmacy Documentation Requirements are outlined below.

b)    Dispensing fee for drugs dispensed in a 1 to 6 days’ supply:

For a pharmacy to be eligible for more than one quarter (¼) of a dispensing fee every 7 days,

•  the drug must have a high potential for dependence, misuse or abuse (drug must be in one of the following categories: narcotic, controlled drug, benzodiazepine or other targeted substance, anticonvulsant, antidepressant, antimanic, antipsychotic or hypnotic), and
• the patient’s drug therapy cannot be managed when dispensed as a 7-day supply, and
• at least one of the following patient factors must apply:
  • Risk of intentional overdose
  • History of drug misuse, abuse, or diversion
  • Severe cognitive impairment, severe mental disability, severe psychiatric illness or severe physical disability

Pharmacy Documentation Requirements are outlined below.
 

Drugs dispensed in a 28 to 100 days’ supply

Refer to Claim Submissions

Drugs dispensed in a 1 to 27 days’ supply that are eligible for additional dispensing fees

Claims must be submitted with the CPhA Intervention Code “ER” and must meet the applicable criteria.

Drugs dispensed in a 1 to 27 days’ supply that are not eligible for additional dispensing fees

The adjudication system cannot identify all situations for which a drug is used continuously:

• Claims for drugs that are typically taken to treat long-term conditions (e.g. high cholesterol, high blood pressure, or diabetes) that are billed for less than a 28 days’ supply will be rejected.
• Claims for drugs that are typically taken for a short period of time but are being taken continuously (e.g. long-term corticosteroid therapy, antibiotic prophylaxis), will not be rejected but the policy applies.

To comply with the policy, pharmacies may need to submit a zero or partial dispensing fee for certain claims:

• Weekly Dispensing (7 Days’ Supply)
  
  Claims must be submitted using “P” in the special services code field, a day supply of “7”, and a claim for a maximum payment of ¼ of the applicable dispensing fee.

• 1 to 27 Days’ Supply Dispensing (excluding 7 Days’ Supply)
  
  Claims must be submitted with the CPhA Intervention Code “ER” using one of the following options below:
  1. Claims must be submitted with a partial dispensing fee, calculated by dividing the applicable dispensing fee by 28 and then multiplying by the number of days’ supply being submitted.
     Examples:
     - Claims submitted for a 10 days’ supply must be submitted with a dispensing fee of $3.93 if applicable dispensing fee is $11 ($11 divided by 28 and multiplied by 10).
     - Claims submitted for a 14 days’ supply must be submitted with ½ of the applicable dispensing fee.
     
     
  2. One claim in a 28-day period, or three claims in an 84-day period, can be submitted with the applicable dispensing fee. Any other claims within those periods must be submitted with a zero-dispensing fee.
     Examples:
     - Claims submitted for a 5 days’ supply: One claim can be billed with the applicable dispensing fee and five claims must be submitted with a dispensing fee of zero over a 28-day period.
     - Claims submitted for a 21 days’ supply: Three claims can be billed with the applicable dispensing fee and one claim must be submitted with a dispensing fee of zero over an 84-day period.

Resubmission of Rejected Claims

If a claim is rejected, it can be re-submitted using the CPhA Intervention Code “ER” with the applicable dispensing fee for the following reason:

• New drug starts
• Dosage changes
• Drugs that are not taken continuously (e.g. acute use, as needed)
• Accommodation for holidays
• Extemporaneous preparations (compounds)
• Criteria for additional dispensing fees are met

The hard copy of the prescription is sufficient documentation to support reimbursement of dispensing fees for the following types of claims:

• New drug starts
• Dosage changes
• Drugs that are not taken continuously
• Accommodation for holidays

For drugs dispensed in a 1 to 27 days’ supply that meet criteria for additional dispensing fees, a frequent dispensing form must be completed for each patient:

• The “Frequent Dispensing Documentation Form for 7 to 27 Days’ Supply” must be completed every year for drugs dispensed in a 7 to 27 days’ supply.
• The “Frequent Dispensing Documentation Form for 1 to 6 Days’ Supply” must be completed every six months for drugs dispensed in a 1 to 6 days’ supply.

Frequent Dispensing Documentation forms:

• May include more than one drug per form.
• A new form is required for a new drug started after a form has been completed and dated.
• Do not need to be sent to the New Brunswick Drug Plans.
• Must be retained for retention period specified in the Pharmacy Act (NB) and related bylaws/guidelines.

All claims submitted to the Plans for reimbursement are subject to audit and recovery. Additional information regarding audit and recovery is available on the Pharmacy Provider Audit webpage.

Completed forms must be retained on file by the pharmacy and readily available for audit purposes. The NB Drug Plans will not accept Frequent Dispensing Documentation forms completed after a pharmacy has been notified of an audit.