Frequency of Dispensing and Payment Policy

Effective July 2, 2013
The Frequency of Dispensing and Payment Policy establishes criteria for dispensing drugs taken continuously (long-term).  This policy was implemented to address the increase in frequency of dispensing of such drugs and associated dispensing fees.

Pharmacies are eligible for one dispensing fee every 28 days or more for drugs taken continuously. 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 prescribed to be taken on an ‘as needed’ basis and dispensed continuously are also included in this policy.

Exceptions are permitted. Documentation requirements for these exceptions are outlined below. All submitted claims are subject to audit and recovery.

The policy does not apply to methadone oral solution since it is not a solid oral dosage form.

Pharmacies are eligible for a dispensing fee on the initial claim for a drug not taken in the last 12 months* that is submitted for a period of less than 28 days if specified on the prescription by the prescriber.  Pharmacies are eligible for a dispensing fee on subsequent claims for the same drug that are also dispensed within the first 28 days if specified on the prescription by the prescriber.  Pharmacies are eligible for a maximum of 4 dispensing fees in the first 28 days of therapy. 

* Note: 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 (including physician samples).

Pharmacies are eligible for a dispensing fee each time there is a dosage change to an existing continuous drug. Pharmacies are eligible for a dispensing fee on subsequent claims for the same drug that are also dispensed within the first 28 days if specified on the prescription by the prescriber.  Pharmacies are eligible for a maximum of 4 dispensing fees in the first 28 days of therapy.

Pharmacies are eligible for one dispensing fee every 28 days or more for drugs prescribed to be taken on an ‘as needed’ basis and dispensed continuously. Pharmacies are eligible for an additional dispensing fee for the same drug within the first 28 days if a new prescription is authorized by the prescriber.

For drugs that are lost or stolen, pharmacies are eligible for a dispensing fee that is the same amount as the dispensing fee paid on the lost or stolen prescription.

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.

Weekly Batch/Cycle Fills

Pharmacies that choose to dispense on a weekly batch / cycle fill basis, can bill claims weekly; however, they are only eligible for ¼ of the dispensing fee, regardless if weekly dispensing has been prescribed or requested. This applies to all New Brunswick Drug Plans beneficiaries including those living in nursing homes, special care homes or residential facilities whose drugs are managed for them.

Bi-Weekly Batch/Cycle Fills

Pharmacies that choose to dispense on a bi-weekly batch / cycle fill basis, can bill claims bi-weekly; however, they are only eligible for ½ of the dispensing fee, regardless if bi-weekly dispensing has been prescribed or requested.

Batch/Cycle Fill other than bi-weekly or weekly

Pharmacies that choose to dispense on cycle fill other than bi-weekly or weekly, can bill claims in this manner, however they are only eligible for a partial dispensing fee up to one dispensing fee every 28 days, regardless if batch/cycle fill other than bi-weekly or weekly dispensing has been prescribed or requested. The claim submission requirements for batch/cycle fills are outlined in the Claims Submission section.

The following exceptions are not permitted for drugs dispensed to patients living in nursing homes, special care homes or adult residential facilities whose drugs are managed for them, regardless if weekly dispensing has been prescribed or requested.

1.    Drugs requiring frequent monitoring of laboratory values:

Drugs that require frequent laboratory tests for therapeutic drug monitoring are eligible for a dispensing fee once every 7 days or more (e.g. lithium, clozapine). The pharmacist must complete an authorization form for each patient.

2.    Patient’s drug therapy cannot be managed when dispensed as a 28-day supply:

For a pharmacy to be eligible for more than one dispensing fee every 28 days, the “Frequent Dispensing Authorization Form for Less Than 28 Day Supply” must be completed yearly.  The pharmacist must complete an authorization form for each patient. One or more of the following reasons must apply:

• Risk of dependence to, or misuse/abuse or diversion of, the drug. This only includes drugs with a high potential for dependence or misuse.
• Documented failure to comply with a drug regimen dispensed in a 28-day compliance package due to cognitive impairment, mental disability, psychiatric illness or physical disability. 
• Individuals with no fixed address who are susceptible to theft or loss of belongings.

3.    Daily Dispensing:

For a pharmacy to be eligible for one dispensing fee every day, the “Frequent Dispensing Authorization Form for Daily Dispensing”, must be completed monthly.  The pharmacist must complete an authorization form for each patient.  Daily dispensing of a drug is for exceptional patients and one or more of the following reasons must apply:

• The patient is at risk of intentional overdose.
• The patient requires daily monitoring until methadone treatment becomes available (please provide date of application).
• Buprenorphine / naloxone (Suboxone™) for opioid dependence during initiation of treatment when daily dispensing is required.
• The patient is taking methadone for opioid dependence and has a documented risk of dependence to, or misuse of, a drug that cannot be addressed with weekly dispensing.  This only applies to drugs with a high potential for dependence or misuse.
• The patient has severe cognitive impairment, severe mental disability, severe psychiatric illness or severe physical disability that cannot be addressed with weekly dispensing. 

Note:

Under the Controlled Drugs and Substances Act, pharmacists are not permitted to alter existing prescriptions or prescribe narcotics, controlled drugs, benzodiazepines and targeted substances. 

Claims submitted for drugs that are typically taken to treat long-term conditions such as high cholesterol, high blood pressure, or diabetes, and are billed for less than 28 days, will receive a rejection message and the claim will not be paid.

Claims submitted for drugs that are typically taken for short period of time but are being taken continuously (long-term corticosteroid therapy, antibiotic prophylaxis), that are billed for less than 28 days will not receive a rejection message.

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

Claims submitted for more frequent payment than this policy allows are subject to audit and recovery.

Intervention Code ER

If a rejection message is received for the following types of claims, the claims must be submitted using the CPhA Intervention Code ER.

• New drug starts
• Dosage changes
• Claims for drugs that are not taken continuously
• Drugs prescribed ‘as needed’
• Replacement of lost or stolen drugs
• Accommodation for holidays
• Extemporaneous preparations (compounds)
• Exceptions to this policy
• Bi-weekly Batch/Cycle Fills
       - Claims must be submitted for a maximum payment of ½
         of the applicable dispensing fee and a day supply of “14”. 
• Batch/Cycle Fill other than bi-weekly or weekly 
       - Claims must be submitted for a maximum payment of
         a partial dispensing fee of the applicable dispensing fee.

Special Service Code P

If a rejection message is received for the following types of claims, the claims must be submitted using the Special Service Code P.  

• Weekly Batch/Cycle Fills
       - Claims must be submitted using “P” in the special service
         code field, a day supply of “7”, and a claim for a maximum
         payment of ¼ of the applicable dispensing fee.

The hard copy of the prescription is sufficient documentation for the following types of claims:

• New drug starts
• Dosage changes
• Claims for drugs that are not taken continuously
• Drugs prescribed ‘as needed’
• Weekly Batch/Cycle Fills
• Bi-weekly Batch/Cycle Fills
• Cycle Fill other than bi-weekly or weekly
• Accommodation for holidays

The hard copy of the prescription with details explaining the following situations is sufficient documentation for the following types of claims:

• Replacement of lost or stolen drugs

Additional documentation is required for the following types of claims:

• Exceptions
  
  The pharmacist must complete the applicable authorization form for each patient.  Completed forms must be retained on file by the pharmacy and readily available for audit purposes. The completed form must be sent to the prescriber only if the claim is submitted for payment more frequently than the instructions on the original prescription.  Completed forms do not need to be sent to the New Brunswick Drug Plans.
  
  1.   Drugs requiring frequent monitoring of laboratory values
  
  The “Frequent Dispensing Authorization Form for Less Than 28 Day Supply” must be completed to indicate how the criteria are met for each drug. The form is valid for a one-year period.
  
  2.   Patient’s drug therapy cannot be managed when dispensed as a 28-day supply.
  
  The “Frequent Dispensing Authorization Form for Less Than 28 Day Supply” must be completed to indicate how the criteria are met for each drug. The form is valid for a one-year period.
  
  3.   Daily Dispensing
  
  The “Frequent Dispensing Authorization Form for Daily Dispensing” must be completed to indicate how the criteria are met for each drug. The form is valid for a one-month period.

Note: The retention period for the “Frequent Dispensing Authorization Forms” is consistent with the requirements in the Pharmacy Act (NB) and related bylaws/guidelines.

• Frequent Dispensing Authorization Form for Less Than 28 Day Supply
  
• Frequent Dispensing Authorization Form for Daily Dispensing

• Payments made for dispensing fees that do not comply with this policy are subject to audit and recovery. Only the ineligible portion of the dispensing fee will be recovered.
  
• Drug Plan will not accept Frequent Dispensing Authorization forms completed after a pharmacy has been notified of an audit.