3.5 Patients - Restricted Claimant Program

Pharmacists, physicians and other healthcare professionals may contact the PharmaCare Help Desk to request restrictions for particular client. Requests can be processed by the PharmaCare Help Desk from 9 am to 4 pm, Monday through Friday, except statutory holidays.

PharmaCare is responsible for determining whether to restrict client access to prescription medications that may be misused. Access is restricted by assigning one (or more) specific physician(s) and/or a single pharmacy in PharmaNet. 

The evaluation and decision process involves a review of the client’s claims history by a designated Ministry of Health pharmacist. Such evaluations may also result from pharmacist/physician requests.

For each client to be restricted, PharmaCare takes one or both of the following two actions:

1. Immediately adds a “Restricted Access” against the client PHN in PharmaNet.
   This invalidates the PHN for all PharmaCare benefits (that is, PharmaCare will not cover any prescription) until information about the client’s physician and pharmacy is added.
2. Calls the client’s physician, to confirm that they are indeed the client’s physician. 
   ​If confirmed, the physician is recorded in the client's PharmaNet file as the “physician of restriction.” If the client’s pharmacy is known, it is also recorded. In some cases, the physician may provide an explanation that makes a restriction unnecessary.

A letter is sent to the “restricted claimant” advising them of the restricted status and asking for the name of one physician and/or pharmacy, if this information has not been obtained. Additional physicians, particularly specialists, will occasionally be added to the client's PharmaNet profile.

Once a client has been classified as a “restricted claimant,” PharmaCare will only consider lifting the restriction:

• After the client has been restricted to that physician for at least six months, and 
• Upon written request from the client’s physician.

The physician makes the request to lift the restriction in writing (by fax or letter) to PharmaCare. A designated pharmacist evaluates the request to lift a restriction by reviewing the client’s claims history. The physician is then notified of the decision by letter.

The lifting of a restriction takes effect immediately. 

In emergency situations, PharmaCare Help Desk staff may make one-day changes to the client’s designated doctor or pharmacy.

Exceptions are made only if the client is unable to see their own doctor or get to their own pharmacy and if not filling the prescription could result in serious harm to the client. 

When a pharmacist calls to request a special exception, they will be asked a series of questions which Help Desk staff use to determine if financial coverage should be provided. 

Help Desk staff will assess if there is a sufficiently good reason why:

• The client is unable to see their own doctor or go to their own pharmacy (e.g., doctor on vacation, pharmacy closed), and 
• This prescription must be filled at this time (i.e., there is a serious health consideration rather than simply a request for an early refill). 

The PharmaCare Help Desk is available Monday through Friday, 9 am to 4 pm. After-hours requests are subject to a more rigorous approval process because of the difficulty in following up with doctors.

Replacement of lost or stolen medications is not covered for clients in this program. 

All special exceptions must be obtained before dispensing as there is no retroactive coverage. 

During normal business hours (9 am to 4 pm, Monday through Friday), the PharmaCare Help Desk can answer calls from clients, pharmacists or physicians regarding restrictions. Or, pharmacists can call the PharmaCare Information Line and choose Option 3 on the main menu to bypass the Help Desk and leave a message requesting a call back.

PharmaNet Help Desk staff may not disclose details of a patient’s previous prescriptions. Pharmacists can check the medication history returned by PharmaNet.

When PharmaCare returns a “Pharmacy not authorized” or “Physician not authorized” message, pharmacists may contact the PharmaCare Help Desk for more information.

Changes to the patient’s designated physician or pharmacy cannot be made automatically at a pharmacist's request. The decision is made, based on PharmaCare policy, by PharmaCare in consultation with Ministry of Health pharmacists and physicians.

After-hours, pharmacists may call the PharmaCare Help Desk to ask about restrictions. Help Desk staff follow PharmaCare policy/guidelines in handling all after-hours enquiries about restricted claimants.

Help Desk staff may not disclose details of a patient’s previous prescriptions. Pharmacists can check the medication history returned by PharmaNet.

If a pharmacist calls after hours, any change made by Help Desk staff (i.e., to the designated physician or pharmacy) will normally be in effect for no more than one business day. After-hours approval will not generally be given for drugs that are frequently misused.

If a restriction is changed temporarily to allow the processing of a specific prescription, only that prescription may be processed. Submission of additional prescriptions will be subject to audit and recovery.

To request a permanent change regarding a restricted claimant, the pharmacist will have to call during normal business hours and speak to Help Desk staff.

The Help Desk cannot make changes to restrictions when they are requested by a client after hours.