5.2 Refilling Prescriptions Too Soon Policy
General Policy Description
PharmaCare does not normally cover prescription refills when there is more than a 14-day supply remaining from a previous fill.
PharmaCare does not cover prescription refills when there is more than a 14-day supply remaining from a previous fill, except when there is a legitimate reason for supplying the medication early and an appropriate intervention code is entered.
This policy does not apply to
- Claims under Plan B (Permanent Residents of Long-term Care Facilities); or
- Supply "top-up" claims eligible for an exception under the Travel Supply Policy
>> Refer to the Travel Supply Policy for policies and procedures for these claims.
For each claim submitted (with the exception of claims under PharmaCare Plan B and reversed claims), PharmaNet automatically
- Adjudicates the current claim to zero if it is being submitted more than 14 days before the expiry of the days' supply of the previous claim and returns the response code "CL – Exceeds Good Faith Limit"
- Identifies the expiry date of the days' supply for the previous claim
- Reviews the days' supply of any previous claim for the same patient and medication submitted up to 100 days before the current date
When there is a legitimate reason for supplying the medication early, pharmacists can submit the claim using the intervention code “UF – Patient gave adequate explanation. Rx filled as written.” Pharmacists are required to document the use of this intervention code, and reason for supplying the medication early, in a manner accessible for audit purposes.
PharmaCare Audit regularly reviews claims accompanied by the UF intervention code to ensure its legitimate use. Inadequate explanation and/or documentation of the use of the UF code may result in Pharmacare seeking recovery of costs.
Note that the CL response code does not supersede the Drug Utilization Evaluation (DUE) D7—Fill Too Soon response. Although the DUE response is usually returned on claims that generate the CL response code, DUE response is based on medical data and continues to provide the most reliable alerts to potential drug therapy or dispensing problems.