5.19 Reimbursement for Non-Returnable High-Cost Injectable Drugs

General Policy Description

PharmaCare allocates an annual pool of funds to provide reimbursement for the adjudicated PharmaCare-paid ingredient cost for an eligible high-cost injectable drug that was ordered for a specific patient but, due to circumstances outside the control of the pharmacy, was not received by the patient.

Reimbursement is subject to the eligibility of a drug as determined by PharmaCare, the availability of funds, and the specific conditions defined below under Reimbursement Policy and Conditions.

Policy Details

Funds allocated for reimbursement each fiscal year will equal 0.25% of total PharmaCare expenditures in the preceding fiscal year for the list of drugs to which this program applies.

If the total cost of reimbursements under this program exceeds the funds available for a particular quarter, reimbursements will be pro-rated based on the proportion of total claimed reimbursements that an individual claim represents.

Funds are allocated evenly across quarters (that is, 25% of the total funds per quarter). Any available funds that are not distributed in a given quarter are carried forward to the following quarter. Any funds not distributed at the end of the fiscal year will be retained by the Province.

A pharmacy may submit a claim for compensation for a reversed claim for an eligible high-cost injectable drug if all the following conditions are met:

  1. The original claim was submitted to PharmaCare and the PharmaCare-paid ingredient cost amount was greater than $0.00.
  2. The drug was ordered to fill a prescription for a specific patient. After the pharmacy ordered the drug, the patient’s treatment was terminated or suspended or the patient was otherwise unable to take delivery of the drug.
  3. The pharmacy had no opportunity to dispense the drug to another patient or return the drug for refund.
  4. The pharmacy has not submitted a previous claim for compensation of a reversed eligible high-cost injectable drug claim for the same patient within the same fiscal year (April 1 – March 31).
  5.  Product loss due to theft, fraud, handling error, equipment or power failure, Act of God or other cause not specifically mentioned above is not eligible for reimbursement under this policy.
  6. The pharmacy must submit a claim for reimbursement by reversing the claim on PharmaNet within 30 days of the patient’s service date for the original claim and use the intervention code specifically assigned for this program.

No retroactive payments can be made for omission of the intervention code or for reversals submitted more than 30 days after the date of the original claim.

Reimbursements will be paid by a financial adjustment to the pharmacy’s payment following the end of the quarter in which the claim is reversed.

 

Procedures

Procedures for pharmacists

Claiming reimbursement for an eligible high-cost injectable drug

Reverse the original claim using the intervention code NR – Non-returnable Drug Reimbursement.

Note that when you submit a reversal with the NR code, PharmaNet appears to process the reversal as a regular reversal—there will be no indication of compensation. This is because NR–Non-returnable Drug Reimbursement reversals are held and processed in a batch once every quarter. Since no financial transaction takes place at the time of submission, no payment message is returned.

Tools and Resources