8.8 Methadone Maintenance Payment Program

General Policy Description

Under the Methadone Maintenance Payment Program, PharmaCare offers pharmacies a payment program for witnessing ingestion of methadone.

This section also includes information on reimbursement and claims submission for methadone for treatment of pain.

Policy Details

PharmaCare offers pharmacies a payment program for pharmacy-witnessed ingestion of only methadone for maintenance.

Eligible products are detailed on the Opioid Agonist Treatment (OAT) DINs and PINs web page.

Methadone is a regular benefit under most PharmaCare plans. Methadone prescribed for pain must be dispensed using the Drug Identification Number (DIN) for the product dispensed.

Pharmacies must use specific PINs and DINs to identify claims for methadone for maintenance and those for the treatment of pain.

[List Updated May, 2019] See the Opioid Agonist Treatment (OAT) DINs and PINs web page.

Participation in the interaction fee portion of the payment program is optional. Pharmacies that elect to participate must

  • Enrol in the Opioid Agonist Treatment Provider sub-class (for more information, see the PharmaCare Provider Enrolment Guide
  • Undertake not to bill patients more than the amounts reimbursed by PharmaCare
  • Agree not to offer cash or incentives of any kind to methadone clients. Without limiting the generality of the foregoing statement, incentives include, but are in no way limited to, air miles, loyalty points and bus passes.

Methadone for maintenance

Pharmacies that choose to participate in the payment program are reimbursed for pharmacist-witnessed ingestion of eligible methadone products at

  • The maximum price PharmaCare covers for the drug, plus
  • The usual dispensing fee, plus
  • An interaction fee of $7.70 for each dispensation involving direct interaction with the patient

Pharmacies that do not enroll in the payment program are reimbursed for eligible methadone products at

  • The maximum price PharmaCare covers for the drug, plus
  • Their usual dispensing fee only

Methadone dispensed under the Methadone Maintenance Payment Program is subject to a maximum of one dispensing fee and one interaction fee per patient per day (in cases where the interaction fee is applicable), regardless of physician administration instructions on the prescription.

Dispensing fees for methadone for maintenance are subject to the Frequency of Dispensing policy, however, PharmaCare continues to pay an interaction fee for each ingestion witnessed.

Methadone dispensations involving direct interaction with the patient must be dispensed under the correct product identification numbers (PINs).

To qualify for interaction fees, the pharmacist must witness the ingestion of the medication by the patient.

There is deemed to be no direct patient interaction when the pharmacist does not witness the ingestion of the methadone dose claimed—e.g., when methadone is provided to incarcerated patients, patients in pre-trial facilities, Plan B patients or to physicians for administration to patients.

Claims for methadone interaction fees in situations when the pharmacist has not witnessed ingestion of the medication are subject to audit and recovery.

Situations that do not involve direct interaction include

  • Dispensing to incarcerated patients
  • Dispensing to patients in pre-trial facilities
  • Dispensing to Plan B patients
  • Dispensing to physicians for administration to a patient
  • Daily pick-ups by patients without a pharmacist witnessing ingestion.
  • Dispensing of “carries” (witnessing the ingestion and dispensing a carry must be submitted in a single claim.)

Methadone dispensations for OAT that do not involve direct patient interaction must be dispensed under the appropriate product identification numbers.

“Carries” must be claimed as a multiple-day supply for drug cost, plus a single dispensing fee and single interaction fee.

Multiple dispensing fees and/or interaction fees claimed for “carries” will be subject to recovery by PharmaCare.

For example, when a pharmacist dispenses a three‑day prescription for methadone, and there is face-to-face interaction with the patient in the form of witnessing ingestion, only one dispensing fee and one interaction fee is permitted for the three-day supply.

The interaction fee is payable to enrolled pharmacies for all PharmaCare-eligible claims (except for Plan B claims), including those above or below the Fair PharmaCare deductible.

Interaction fees are calculated automatically using transaction data from PharmaNet. Payments are made monthly on the last payment of the following month.

Plan B

Methadone for maintenance patients covered under Plan B must also be dispensed under the appropriate product identification numbers for methadone for maintenance and are reimbursed as follows:

  • Actual acquisition cost to the maximum price PharmaCare covers for the drug.
  • Usual Plan B capitation rates will be paid.

Fair PharmaCare

PharmaCare pays methadone interaction fees for Fair PharmaCare patients regardless of whether they have met their annual deductible.

Persons born before 1940

PharmaCare covers 100% of the cost of methadone for maintenance and associated dispensing fees for persons born before 1940, whether or not they are registered for Fair PharmaCare.

Persons born on or after January 1, 1940, do not qualify for this coverage even if their spouse receives enhanced Fair PharmaCare coverage.

This fee coverage applies only to Methadone Maintenance Payment Program dispensing fees. 

Pharmacies can process methadone maintenance transactions as normal for these patients; PharmaCare automatically pays the dispensing fees for eligible seniors on those transactions.

Non-Insured Health Benefits (NIHB) clients

PharmaCare does not cover methadone for clients of the Non-Insured Health Benefits (NIHB) program.

The NIHB program covers the cost of methadone for eligible clients. Methadone is an open benefit under the NIHB.

For more information, pharmacies can contact the NIHB Toll-free Inquiry Centre (First Canadian Health Management Corporation) at 1 888 511-4666, Monday - Friday, 6:30 AM to midnight (EST) and, on weekends and holidays, from 8 AM to midnight (EST).

The accuracy and validity of methadone claims is verified on a monthly basis.

Reminder—Batch Claims Policy

As stated in the PharmaNet Compliance Standards, it is acceptable to submit batch claims only if you are submitting claims for

  • Residential care facility patients
  • Prescriptions filled during a network outage (within 24 hours of reconnecting to the network)

 

Procedures

Entering claims for methadone

Enter the claim using the correct PIN (for maintenance) or DIN (for pain). Refer to the OAT DINs and PINs page for detailed instructions for specific products/strengths and interaction fees.