8.3 Frequency of Dispensing Policy - Fee Limits

Under the Frequency of Dispensing Policy PharmaCare limits the number of dispensing fees it covers for patients receiving:

• Daily dispensing, and/or
• Dispensing every 2 to 27 days

PharmaCare continues to cover one dispensing fee when a single fill is provided for:

• The total quantity the prescriber specified on the prescription, or
• No less than the Maximum Days' Supply allowed under PharmaCare policy

However, PharmaCare limits the number of dispensing fees covered when:

• A prescriber orders daily dispensing, or
• A prescriber orders or a pharmacist initiates dispensing in 2- to 27-day supplies
• A pharmacist renews a prescription with daily dispensing

The Ministry of Health may audit pharmacy claim records and will recover funds if the number of dispensing fees paid exceeds those allowed under this policy.

Included products

Opioid Agonist Treatments	The Frequency of Dispensing Policy applies to prescriptions for opioid agonist treatments. For methadone for maintenance, PharmaCare continues to pay an interaction fee for witnessing ingestion.
Plans C (Income Assistance), Fair PharmaCare, D (Cystic Fibrosis), F (Children in the At Home Program), G (Psychiatric Medications), P (Palliative Care) and W (First Nations Health Benefits)	All the plans listed are subject to the Frequency of Dispensing Policy.

Exempted products

Plan B (Long-term Care)	The Frequency of Dispensing Policy does not apply to long-term care patients covered under PharmaCare Plan B. All other plans are subject to the maximum number of fees specified below.
Treatment of an acute condition	PharmaCare will accept a dispensing fee if a pharmacy dispenses, in a single fill, the entire prescribed supply of a medication for a defined duration of therapy with a days' supply of 27 days or less—that is, a medication intended to treat a temporary or intermittent condition (e.g., antibiotics, antifungals, antivirals, short-term pain medications, etc.). Please refer to the Intervention Code information for details.
First fills of a new chemical entity as an interim supply	A pharmacy dispenses a first fill of a new chemical entity as an interim supply to last until the patient's next scheduled compliance package is prepared. Please refer to the Intervention Code information for details.

Exclusion of inhalers, nebulizers and nitroglycerin sprays

As of October 15, 2009, certain inhalers, nebulizers and nitroglycerin sprays were excluded from the Frequency of Dispensing policy. As new products of this type become available, the list may be expanded.

See the list of excluded inhalers, nebulizers and nitroglycerine sprays (PDF, 286KB).

Inquiries about the potential inclusion of other products such as this (i.e., those that may create a quantity issue when the Frequency of Dispensing policy is applied) can be emailed to the Ministry of Health, Pharmaceutical, Laboratory and Blood Services Division at pharma@gov.bc.ca.

Fee limits are per pharmacy. That is, if a patient fills prescriptions at more than one pharmacy on the same day, each pharmacy can claim the maximum number of fees allowed under the policy.

However, dividing patient claims between two or more pharmacies in order to circumvent the maximum number of fees covered under the Frequency of Dispensing Policy is not permitted and is subject to audit by the Ministry of Health.

As is the case for all claims, entering the appropriate days' supply is important.

For instance, for PRN (take as needed) medications, calculate the days' supply based on the maximum dosage per day indicated on the prescription. This prevents a patient who needs the full dosage each day from running short of medication before the expiry of the days' supply. This makes sure that the Refilling Prescriptions Too Soon Policy, Travel Supply Policy and Frequency of Dispensing Policy will be applied appropriately.

If the prescriber handwrites "dispense daily/daily dispensing"* on the original prescription, or includes the order on a prescription generated from the physician's EMR system, PharmaCare covers:

• One (1) dispensing fee per patient, per drug (DIN), per day—to a maximum of three (3) dispensing fees per patient, per day

PharmaCare covers a dispensing fee only if the date of the original prescription is no more than 100 days earlier than the dispensing date.

If a prescription is dated more than 100 days earlier than the dispensing date, the prescriber must re‑authorize daily dispensing in handwriting on a new prescription.

After a patient has reached the maximum number of daily dispensing fees, pharmacies cannot change a physician’s order for daily dispensing to every-second-day dispensing, or any other dispensing frequency, for the purposes of obtaining extra dispensing fees.

If a health authority pharmacist is given a verbal order from a physician to handwrite "dispense daily/daily dispensing"* on a prescription, PharmaCare will cover the dispensing fees when that prescription is sent to a community pharmacy.

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*PharmaCare Audit cannot accept the abbreviation “DD” on the prescription.

If the prescriber orders medication to be dispensed in a two- to 27-day supply in writing on the original prescription or includes the order on a prescription generated from the physician’s Electronic Medical Record system (i.e., by writing “Blister packs/packing,” “Weekly dispensing,” “Compliance packaging,” or “Bi-Weekly dispensing”), PharmaCare will cover:

• One (1) dispensing fee per patient, per drug (DIN), per prescribed supply—to a maximum of five (5) fees per patient, per prescribed supply

Example 1: If the prescriber orders weekly compliance packaging, PharmaCare covers one (1) dispensing fee per patient, per drug (DIN), per week—to a maximum of five (5) fees per patient per week.

Example 2: If the prescriber orders bi-weekly dispensing, PharmaCare covers one (1) dispensing fee per patient, per drug (DIN), every two weeks—to a maximum of five (5) fees per patient every two weeks.

Required documentation for verbal prescriptions

If a pharmacy receives verbal authorization to dispense a prescription frequently, the pharmacy will not have any documentation to support a claim for fees for frequent dispensing. To claim a fee, the pharmacy must complete a HLTH 5378 - Frequent Dispensing Authorization (PDF, 543KB), check the “2-27–day dispensing verbally authorized by prescriber” box, then fax the form to the prescriber.

Faxed refill authorizations

If a pharmacy transmits a refill authorization to a practitioner, the pharmacy will not have any independent documentation to show that frequency of dispensing was initiated by the practitioner. To support a claim for fees for frequent dispensing, the pharmacy must either:

• Ask the practitioner to provide the pharmacy with a refill authorization produced by the practitioner’s office requesting frequent dispensing; or
• Complete a HLTH 5378 - Frequent Dispensing Authorization (PDF, 543KB), check the “2-27–day dispensing verbally authorized by prescriber” box, then fax the form to the prescriber

If the patient meets the criteria below and the appropriate form is completed, PharmaCare will cover:

• One (1) dispensing fee per patient, per drug (DIN), per authorized supply, to a maximum of five (5) fees per patient per authorized supply

Clinical criteria guideline for a two to 27-day supply

For coverage of dispensing fees, a patient must be unable to manage their drug therapy independently. That is, a patient must exhibit one or more of the following:

If a patient exhibits one of more of the clinical situations above, the pharmacist must:

• Complete the HLTH 5378 - Frequent Dispensing Authorization (PDF, 543KB) indicating the clinical criteria that support more frequent dispensing.
• Obtain the signature of the patient or their representative.
• Fax a Frequent Dispensing Authorization to the physician(s) who prescribed the drug(s).
• Retain proof of fax (i.e., fax verification form) on file and retain the Frequent Dispensing Authorization in accordance with College of Pharmacists of B.C. policies and bylaws. PharmaCare cannot accept forms that have been mailed or hand-delivered to the physician’s office. PharmaCare cannot accept fax reports listing multiple faxes.

A prescriber who disagrees with the frequency of dispensing can complete the last section of the form and fax it to both the pharmacy and PharmaCare. See When a prescriber disagrees with frequent dispensing for a patient for more information.

PharmaCare cannot accept Frequent Dispensing (FD) Authorization forms completed after a pharmacy has been notified of an onsite audit.

Patients with multiple dispensing frequencies or multiple prescribers

Pharmacies must notify the practitioner who prescribed the drug being dispensed (the “prescriber”). If the patient has active prescriptions from multiple prescribers, complete the HLTH 5378 - Frequent Dispensing Authorization (PDF, 543KB) indicating each prescriber, then fax the completed form to each prescriber to notify them. If the patient has more than six prescribers, complete additional Frequent Dispensing Authorization forms as needed.

If a patient is receiving medications on more than one dispensing frequency, a separate form must also be completed for each frequency.

Prescription transfers

When a prescription is transferred from one pharmacy to another pharmacy, the receiving pharmacy is responsible for completing a HLTH 5378 - Frequent Dispensing Authorization (PDF, 543KB) and faxing it to the prescriber(s).

Required annual renewal—Frequent Dispensing Authorization forms

The Frequent Dispensing Authorization form for each patient must be renewed each year, on or before the date the patient signed the original form.

Download the form (PDF, 543KB) or order printed supplies through the PharmaCare Help Desk.

The prescriber name submitted with a claim must agree with the prescriber name on the HLTH 5378 - Frequent Dispensing Authorization (PDF, 543KB).

Intervention code—treatment of an acute condition

Enter the following intervention code and a fee will be covered.

Intervention Code	UT—Treatment of an Acute Condition
Requirements	Use this code only When dispensing, in a single fill, the entire prescribed supply of a medication for a defined duration of therapy with a days' supply of 27 days or less—that is, a medication intended to treat a temporary or intermittent condition (e.g., antibiotics, antifungals, antivirals, short-term pain medications, etc.) When a patient is receiving frequent dispensing. Do not use this intervention code for subsequent repetitive fills of the same medication.
PharmaNet Response	No response code is returned.
Documentation	Use of this intervention code is subject to audit. PharmaCare requires pharmacists to document the reason for the use of an intervention code in a manner accessible for audit purposes. If the documentation of the use of the intervention code is recorded on the pharmacy’s computer system, auditors require access to the pharmacy's computer system.

Intervention code—first fill of a new chemical entity as an interim supply OR an early fill of an existing frequently dispensed prescription

Intervention Code	DQ—Professional Fee Appropriate
Requirements	A pharmacy dispenses a first fill of a new chemical entity as an interim supply to last until the patient's next scheduled compliance package is prepared. The pharmacist must ensure that their pharmacy has not dispensed the chemical entity to the patient in the last 14 months by checking claim records and the PharmaNet profile. A change in strength, formulation and/or brand of a chemical entity already included on the patient’s PharmaNet profile does NOT constitute a first fill of a new chemical entity. The first fill of the new chemical entity must be adjudicated at least one day before the dispensing of the next compliance package. OR A patient requires an early fill of an existing frequently dispensed prescription (for instance, due to a statutory holiday). The maximum of 5 dispensing fees per authorized supply still applies; therefore, in this scenario, the intervention code must only be used up to the first 5 claims.
PharmaNet Response	No response.
Documentation	Use of this intervention code is subject to audit. PharmaCare requires pharmacists to document the reason for the use of an intervention code in a manner accessible for audit purposes. If the documentation of the use of the intervention code is recorded on the pharmacy’s computer system, auditors require access to the pharmacy's computer system.

Intervention code—patient pay

Intervention Code	VG—Professional Service Fee Not to be Paid
Requirements	A patient requests frequent dispensing and the pharmacist determines the patient does not meet the clinical criteria for 2‑ to 27-day supplies. That is, the patient does not exhibit one or more of the following: Cognitive impairment History of abuse or poor compliance No support structure (to assist with administration of drug therapy) Risk of dependence Susceptible to theft or loss of belongings Complex medication regimen Physical or mental disability Literacy issues Language issues Non-compliance or misuse is suspected The patient chooses to pay the fees. Code cannot be used if the patient meets the clinical criteria for frequent dispensing.
PharmaNet Response	PharmaNet will respond with DH—Professional fee adjusted.
Documentation	None required.

When the total number of active dispenses reaches five, no additional fees are payable.

What is an "active dispense"?

Whenever a prescription is dispensed, PharmaNet:

• Checks for fills of any medication in the previous 27 days, then
• Checks the days' supply of these previous fills, and
• Calculates the patient's remaining days' supply.

If the remaining days’ supply is more than one day, the claim is considered an "active dispense."

What is not considered an active dispense?

The following are not counted as active dispenses:

• Claims for non-benefit items
• Claims for non-drug items
• Claims for patients not covered under PharmaCare
• Claims submitted with the following intervention codes:
  • UT (Treatment of an Acute Condition / Full prescribed supply dispensed)
  • VG (Professional Fee Not to Be Paid)
  • MR (Lost or stolen)

Examples of how active dispenses are counted

When a patient receives all their medications in a weekly compliance/blister pack, the pharmacy is normally eligible for five dispensing fees for that patient each time the blister pack is dispensed. However, in some cases, patients may require medications outside the usual schedule.

Examples: How Active Dispenses Are Counted (PDF, 113KB) shows how 'active dispenses' are counted in more unusual circumstances such as when a patient has all their medication in weekly blister packs but receives some medication outside the normal dispensing schedule or when a patient has a mix of weekly blister packs and other medications.

A prescriber has the right to disagree with frequent dispensing initiated by a pharmacist. If a prescriber considers frequent dispensing to be unwarranted, PharmaCare does not cover dispensing fees. PharmaCare may recover fees paid after the date on which the prescriber notified the pharmacy.

If the prescriber disagrees with frequent dispensing, the pharmacist can choose to:

• Consult with the prescriber to ensure the prescriber is aware of any concerns, or
• Consult the patient to determine if they have another insurer who might cover the fees for frequent dispensing

If the patient chooses to pay the fees, use the appropriate intervention code to allow the patient to pay.

If you consult the prescriber and the prescriber subsequently agrees that frequent dispensing is warranted, please complete a new Frequent Dispensing Authorization (HLTH 5378) (PDF, 543KB) and fax it to PharmaCare and the physician.

If you choose not to consult the prescriber or, after consulting the prescriber, he/she does not support the frequency of dispensing, you must discontinue frequent dispensing for that patient—unless the patient chooses to continue and pay for it themselves.

PharmaNet adjudication allows:

• Up to three (3) dispensing fees per patient for the drugs (DINs) dispensed daily
• Up to five (5) dispensing fees per patient for the drugs (DINs) dispensed in a 2- to 27-day supply

For example, if a patient receives five prescriptions dispensed daily and six prescriptions dispensed weekly, PharmaNet will allow three dispensing fees per day for the drugs dispensed daily and five fees per week for the drugs dispensed weekly.

Please note that combining two frequencies of dispensing when treating a patient is being monitored and pharmacies may be asked to provide the supporting documentation, specifically

• For the drugs dispensed daily: the original prescription with the physician's handwritten order or the order on a prescription generated from the physician’s Electronic Medical Record system (i.e., “Dispense Daily/Daily Dispensing”) for daily dispensing.
• For the drugs dispensed in two- to 27-day supplies: the original prescription with the physician's handwritten order or the order on a prescription generated from the physician’s Electronic Medical Record system (i.e., “Blister Packing/Packaging”, “Weekly Dispensing, “Compliance Packaging,” “Bi-weekly Dispensing”) for frequent dispensing OR the HLTH 5378 - Frequent Dispensing Authorization form (PDF, 543KB).

If a patient ceased receiving frequent dispensing and now requires frequent dispensing again, pharmacists must treat it as a new request. That is, for daily dispensing, pharmacists must have a properly-annotated prescription from the physician. For 2 to 27-day dispensing, the pharmacist must have a properly annotated prescription requesting frequent dispensing from the physician or must complete a HLTH 5378 - Frequent Dispensing Authorization form (PDF, 543KB) and fax it to the prescriber, retaining proof of fax on file.

Pharmacies cannot bill PharmaCare weekly for a travel supply issued on a single date. For instance, if a patient requires three weeks of compliance-packaged medications, but the full three weeks’ supply is dispensed at the same time, the pharmacy would not be permitted to claim a fee for the second and third week.

Notify each prescriber who prescribed a drug that is being dispensed frequently.

If a patient has multiple prescribers and all the patient's prescriptions will be frequently dispensed (e.g., in a weekly blister pack), complete a separate HLTH 5378 - Frequent Dispensing Authorization (PDF,543KB) indicating each prescriber (and for each dispensing frequency, if applicable) and fax the completed form to each prescriber.

No. For patients below the Fair PharmaCare deductible, PharmaNet tallies the maximum number of allowable fees only to determine how much should count towards the patient's deductible. The LZ code is returned for fees above the maximum, but, as no dispensing fee would have been covered anyway, it makes no difference to the pharmacy's payment.

Yes. The Refilling Too Soon policy introduced in 2002 is still in place. Under this policy neither the drug cost nor the dispensing fee is covered if a patient has more than 14 days' supply of medication left from the previous fill. This policy applies to all medications whether or not they are considered "frequently dispensed."

The Travel Supply Policy introduced in 2008 also still applies. PharmaCare continues to allow an earlier fill once every six months (180 days) if a patient will be travelling outside B.C. Patients can top up their supply to the maximum days’ supply recognized by PharmaCare as long as they complete and sign a Travel Declaration form (supplied by the pharmacy) on the date their prescription(s) is filled.

Yes. A physician’s order for frequent dispensing included in a prescription generated from the physician’s Electronic Medical Record system is acceptable.