8.5 Special Services Fees

General Policy Description

Sometimes a pharmacist may choose not to dispense a prescription for reasons such as a drug-to-drug interaction or suspicion of multi-doctoring.

In some “refusal to fill” situations, the pharmacist may be entitled to claim a PharmaCare fee for “special services.”

Policy details

When a special services fee can be claimed

The original prescription must be entered and reversed before a special services fee can be claimed. (See Procedure for details.)

PharmaCare pays a special services fee to any PharmaCare provider who does not dispense a prescription after reviewing information on PharmaNet when the PharmaCare paid amount for the original prescription is greater than $0.00. Special-services fee claims must be submitted on the same day as the reversal.

When a pharmacist refuses to fill a prescription for suspected poly-pharmacy/ multi-doctoring and processes a claim for a special services fee, the prescription can be returned to the patient. To prevent the patient from presenting the prescription to another pharmacist, mark the prescription with the notation “refused to fill” and the date before returning it.

Following are situations in which a special-services fee may be claimed. The pharmacist must provide appropriate justification for the refusal-to-fill by using one of the applicable Canadian Pharmacists Association (CPhA) intervention codes. 

The approved CPhA intervention codes are:

Description	CPhA Code
Significant Drug Interaction (Drug-to-Drug)	CI
Prior Adverse Reaction	CA
Therapeutic Duplication	CD
Sub-Therapeutic Dose	CL
Dangerously High Dose	CH
Treatment Failure	CB
Potential Overuse/Abuse	CO
Suspected Polypharmacy/Multi-Doctoring	CM
Falsified/Altered Prescription	CF
Consulted Prescriber—Changed Dose	UB
Consulted Prescriber—Changed Instructions for Use	UC

When a special services fee cannot be claimed

A refusal-to-fill in response to a patient asking for an early fill of a prescription does not qualify for a special services fee.

Fees may not be claimed for repeat occurrences involving the same individual at the same pharmacy within a short time.

Because PharmaCare makes capitation payments for those living permanently in long-term care (PharmaCare Plan B patients), it does not pay special services fees for Plan B claims.

Special services fee—maximum allowable fee

The maximum special services fee paid is twice the amount of the pharmacy’s normal PharmaCare dispensing fee, at the time of the dispensing request.

Audit

Please note that special services fees are subject to audit by PharmaCare.

Procedures for pharmacies

Pharmacies using version 3 software

1. Submit the original prescription.
2. Reverse the prescription using one of the intervention codes above on the same day as the prescription fill.
3. Submit the claim again on the same day as the reversal and with the following information:

• The special services fee code (consult your vendor for information if necessary)
• Intervention/exception codes
• $ amount of the special services fee (in the ZCD segment)

Pharmacies using version 70 software (updated to support Provincial Prescription Management [PPM])

1. If the prescription authorization has not been uploaded to PharmaNet (i.e., for paper or faxed prescriptions received at the pharmacy), upload the prescription with the details as written by the prescriber. Do not perform a dispense/claim adjudication. 
2. Update the prescription authorization status to 'O – Obsolete' by submitting a TRX-X2 transaction.

• Ensure the following are entered as this information is used by PharmaCare to provide payment to pharmacies:
  • Reason code = RF (Refusal to Fill)*
  • Medication Management Intervention (MMI) code = RTF (Refusal to Fill)*
  • Clinical Service (CS) code - as appropriate, refer to table below

Clinical Services codes

CS code	Description
ATPR	ALLERGY TO PRODUCT IS ON RECORD
CGDS	CONSULTED PRESCRIBER – CHANGED DOSAGE
CGIN	CONSULTED PRESCRIBER – CHANGED INSTRUCTIONS FOR USE
DNGR	DANGEROUSLY HIGH DOSE
DUPL	THERAPEUTIC DUPLICATION
FALS	FALSIFIED/ALTERED PRESCRIPTION
MULT	MULTI-DOCTORING/MULTI-PHARMACY
PADR	PRIOR ADVERSE REACTION
PINE	PRODUCT IS NOT EFFECTIVE
PTOA	POTENTIAL OVERUSE/ABUSE
QPNR	QUANTITY PRESCRIBED IS NOT RATIONAL
SDTD	SIGNIFICANT DRUG INTERACTION (DRUG-TO-DRUG)
SUBD	SUB-THERAPEUTIC DOSE
TFLR	TREATMENT FAILURE

Performing this action will prevent the prescription authorization from being filled in the future. It is important the pharmacist only takes this action for prescriptions that are true refusals to fill and not a situation where a client is requesting an early fill of a medication. For additional questions about entry procedures, pharmacies are encouraged to contact their software vendor.