Limited coverage drugs
PharmaCare covers some drugs only for patients who meet specific clinical criteria. These are “limited coverage” drugs. They are typically:
- Not first-line treatments
- More expensive than a fully-covered alternative
Some limited coverage drugs have significant patient safety considerations.
Every limited coverage drug has patient clinical criteria for coverage. Patients must meet the clinical criteria for coverage to be approved.
You can access the criteria by clicking on the drug name in the Special Authority drug list.
Note the Practitioner Exemptions section, which lets you know if an exemption or CPA is available.
Coverage for limited coverage drugs is provided through PharmaCare Special Authority (SA).
In most cases, prescribers apply for SA coverage for their patient. They apply through SA eForms or using a paper form. eForms is substantially quicker, though not yet available to all prescribers.
In their request, the prescriber demonstrates that the patient meets the clinical criteria.
For some drugs, some specialist groups are exempt from applying, and SA coverage is automatic. Prescribers can also enter a Collaborative Prescribing Agreement (CPA) for some drugs, which also makes SA coverage automatic. See Practitioner exemptions and CPAs below.
- Special Authority: The prescriber submits a request for coverage, which is linked to PHN
- Practitioner exemptions: The prescriber automatically has coverage for their patients for that drug, based on prescriber specialization. The coverage is linked to Prescriber ID
- Collaborative Prescribing Agreement (CPA): The prescriber signs the agreement, and coverage is automatic for their patients for that drug. The coverage is linked to Prescriber ID
The clinical criteria for each limited coverage drug has a section titled Practitioner Exemptions, which indicates if a practitioner exemption or CPA is available.
If a practitioner exemption is available, prescribers under the identified specialty or specialties do not need to submit SA coverage requests for their patients to receive coverage for the drug. Practitioner exemptions are automatic in PharmaNet. Prescribers do not need to apply for the exemption.
If a CPA is available, an eligible prescriber can sign the agreement. they are then exempt from submitting an individual request for coverage of specific drugs for patients who meet the criteria.
When they enter a CPA, a physician agrees to:
- Prescribe according to the limited coverage criteria specified in the CPA
- Allow PharmaCare to assess whether they’re adhering to the prescribing criteria
- Annotate prescriptions for patients who do not meet the criteria in such a way that the pharmacy will not bill PharmaCare for the drug
PharmaCare has the right to require the renewal of a CPA or to discontinue a CPA if the prescriber is not adhering to the coverage criteria specified in the CPA.
CPAs save time on the part of prescribers and Special Authority. However, CPAs are viable only if prescribers adhere to their terms.
Usually when a prescriber writes “Submit as zero cost to PharmaCare” or “PharmaCare pays zero” on a prescription, it means the patient is not eligible for PharmaCare coverage.
Occasionally, this note means that a Collaborative Prescribing Agreement (CPA) is in place and the patient does not meet the conditions associated with it. If you are filling a prescription with a “zero cost” or “pays zero” note for this reason, enter the intervention code DE Adjudicate to $0.00 as requested. This is the same code used when a patient is not eligible for coverage.
Note: PharmaCare coverage is not retroactive. SA approval or a CPA must be in place before a patient fills a prescription.
Examples of CPAs and practitioner exemptions
- The CPA for dalteparin: “PharmaCare coverage will be provided for a patient who meets the limited coverage criteria, and whose prescription is written by an orthopedic surgeon who has entered into a Collaborative Prescribing Agreement (PDF, 291KB). Due to the individual nature of each Collaborative Prescribing Agreement, the agreement must be signed by the prescriber and not their delegate.”
- The Practitioner Exemptions section for chloroquine: “Practitioners in the following specialty are not required to submit a Special Authority request for coverage: Rheumatologists”
- The Collaborative Prescribing Agreement (CPA) (PDF, 400KB) for glatiramer acetate.
CPAs and practitioner exemptions are tied in PharmaNet to the prescriber’s ID. If a different prescriber, who does not share the specialty or CPA, rewrites a prescription, and their ID is entered in PharmaNet as the prescriber, the patient will not have coverage for that drug.
If this occurs, check the patient’s PharmaNet profile and/or ask the patient for more information. If you identify another prescriber able to prescribe under a CPA or practitioner exemption, you can contact that prescriber, confirm they intend for the patient to receive the prescription, and enter that prescriber’s ID in the claim. It is acceptable to confirm the prescription information by phone, but you must document any change to the Prescriber ID on the script.
Note: Many practitioner exemptions extend to subsequent prescribers. These are referred to as “assumed SAs.” If the patient’s PharmaNet profile shows previous coverage for a limited coverage drug and you think an assumed SA should be in place, please call the PharmaCare Help Desk.
Under some circumstances, pharmacists may request SA coverage. In these cases, the pharmacist would be:
- Acting as the prescriber for OTC medications such as acetaminophen or NRTs
- Adapting for first-line ARBs or PPIs
- Applying for exceptional Plan Z coverage
- Dispensing vancomycin following a hospital stay, or
- Working in a clinical setting, has access to the patient’s full medical record, and is working in collaboration with a prescriber