5.10 Full Payment Policy

[June 7, 2019: Updated to correct oversight in affected plans section]

General Policy Description

Under the Full Payment Policy, pharmacies are not permitted to charge any amount directly to patients who are receiving full PharmaCare coverage for a claim.

Policy Details

The Full Payment Policy applies to all pharmacy providers that submit claims to PharmaCare.

Pharmacies must not charge any amount directly to an individual receiving full PharmaCare coverage for a drug, substance, or related service that is a full benefit.

Individuals receiving full PharmaCare coverage are those covered under PharmaCare plans B, C, D, F, G, P, W, Z, and those that have reached their Fair PharmaCare (Plan I) family maximum.

A drug, substance, or related service is a full benefit when it is

  • A regular PharmaCare benefit (that is, no Special Authority required), or
  • A Limited Coverage drug for which Special Authority approval has been granted, and
  • Not subject to any reimbursement limit on adjudication under the Low Cost Alternative Program or Reference Drug Program.

The Full Payment Policy does not apply when the drug, substance, or related service

  • Is not a PharmaCare benefit
  • Adjudicates as a partial PharmaCare benefit under the Low Cost Alternative Program or Reference Drug Program
  • Is exempt from the Full Payment Policy

The following products are exempted from the Full Payment Policy:

  • Insulin
  • Medical supplies and devices including
    • prosthetics
    • orthotics
    • ostomy supplies
    • cystic fibrosis nutritional supplements/vitamins
    • diabetes supplies (insulin pumps and supplies, needles and syringes, continuous glucose monitors and blood glucose test strips)

When a pharmacy provider mistakenly charges drug, substance, related service, or dispensing fee costs directly to an individual for a claim to which the Full Payment policy applies, the pharmacy provider must refund those charges to the individual.

 

Procedures

When submitting claims to which the Full Payment Policy applies, do not charge patients for any amount in excess of that accepted for reimbursement by PharmaCare.

Questions and Answers

When multiple plans are involved, a patient may have claims that are subject to the Full Payment Policy and others that are not.

Example: Robert arrives with two prescriptions. One is for a psychiatric medication covered under Plan G. The other is for ointment covered under Fair PharmaCare. The claim for the psychiatric medication will be subject to the Full Payment Policy. Robert has met his Fair PharmaCare deductible but has not yet reached his Family Maximum, so the claim for the ointment will not be subject to the Full Payment Policy.

If a pharmacy provider is able to determine at the time medication is dispensed that the patient’s private insurer will cover any costs in excess of the amount PharmaCare covers, they can charge the private insurer.

A pharmacy provider cannot charge a patient on the understanding that a private insurer may pay all or some of the cost at a later date. The determination of coverage by the private insurer must be made at the time the product is dispensed.

 

Tools and Resources