5.1 Maximum Days Supply Policy

General Policy Description

The Maximum Days' Supply policy limits PharmaCare coverage of drugs to either 30 or 100 days to address concerns over public safety and the cost of drug wastage by reducing the potential for leftover supplies of drugs.

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Policy details

Accurate entering of days' supply

To ensure the appropriate adjudication of claims, pharmacies are to accurately enter into PharmaNet the days' supply for the drug dispensed.

Claims with an inaccurate days supply may be subject to audit and recovery.

Application of the 100-Day Maximum Days' Supply

PharmaCare limits coverage to a maximum 100-day supply for repeat fills for long-term maintenance drugs.

Application of the 30-Day Maximum Days' Supply

PharmaCare limits coverage to a maximum 30-day supply for:

• All fills for short-term drugs and other drugs assigned a 30-day supply maximum by PharmaCare; and
• First fills for long-term maintenance drugs to ensure the drug is effective and tolerated by the patient.

Short-term drugs include all narcotics, all antibiotics, antifungals, sedatives, sleeping pills, barbiturates and all drugs in the Plan P (Palliative Care) formulary.

Prescriptions subject to the maximum 30-day supply for first fills policy include:

• A prescription for a new chemical entity
• A prescription that involves a change in dosage (strength or dosing frequency) of a previously prescribed chemical entity
• A new prescription for a previously prescribed chemical entity after a lengthy break in therapy (approximately four months or longer)

PharmaNet cannot distinguish between first fills and refills. Pharmacists are responsible for determining whether a prescription is a first fill for a long-term maintenance drug (maximum 30-day supply) or a repeat fill (maximum 100-day supply). Pharmacists should review the patient medication history and ask the prescribing physician or the patient to determine whether the prescription is a first-time fill or a repeat fill.

The PharmaCare Formulary Search may be used to determine if a particular drug is subject to a 30-day maximum supply. Note that a 35-day maximum supply shown in the Formulary Search indicates a drug is subject to a 30-day maximum supply. The 35-day maximum supply shown is applicable only to Plan B patients.

The following are automatically exempt from the 30-day maximum days supply:

• Claims under PharmaCare Plan B are exempt to accommodate the 35-day monitored dosage system that may be used by pharmacies servicing long-term care facilities, and 
• Prescriptions dispensed under the Trial Prescription Program (where a 14-day trial has been dispensed)

[Amended August 24, 2016] In the case of individuals residing in rural or remote areas for whom travel to the pharmacy is a significant barrier, the pharmacist can call the PharmaCare Help Desk to request an exemption.

>> See Procedures for pharmacists, below. 

In the case of certain chronic conditions, physicians may submit a General Special Authority Request (HLTH 5328) asking PharmaCare to exempt a patient from the 30-day maximum supply for a short-term drug. Approval may be granted allowing for a 100-day supply.

>> See Section 6.3—Special Authority Coverage, Special Authorities for Exceeding Maximum Days’ Supply.

Procedures

Procedures for pharmacists

Processing a prescription for a remote/rural exemption

To process a rural or remote exemption:

1. Ensure that the patient qualifies.
2. Call the PharmaNet Help Desk and request the exemption.
   The Help Desk will enter the exemption as a one-day Special Authority.
3. Write “Rural Supply Exemption” on the prescription for audit purposes.

Correcting a claim when the 30-day supply limit has been mistakenly applied

If a 30-day supply limit has been applied mistakenly, the pharmacist may reverse the transaction and dispense a 100-day supply. This action is not eligible for a Special Services Fee.