5.1 Maximum Days Supply Policy

General Policy Description

The Maximum Days' Supply policy limits PharmaCare coverage of drugs to fills of either 30 or 100 days to address concerns over public safety and drug wastage.

On this page:

• Policy details
• Procedures

Policy details

To ensure the appropriate adjudication of claims, pharmacies must enter in PharmaNet the accurate days' supply for the drug dispensed.

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

100-Day Maximum Days' Supply

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

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 Palliative Care Drug Plan (Plan P) 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 (i.e., 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 client medication history and ask the prescribing physician or the client to determine whether the prescription is a first fill or a repeat fill.

The PharmaCare Formulary Search can 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 clients.

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)

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.

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 for a 100-day supply.

Visit Special Authority Coverage, for details on 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 client 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.