Limited Coverage Drugs
Limited coverage drugs are covered by PharmaCare for patients who meet specific medical criteria. These drugs are typically:
- not first-line treatments;
- more expensive than fully covered alternatives.
Additionally, some limited coverage drugs have significant patient safety considerations.
Coverage for these drugs can be provided in one of three ways:
|1. Special Authority (SA)||2. Collaborative Prescribing Agreement (CPA)||3. Practitioner Exemptions|
|Requested by prescriber||Prescriber signs the agreement, and coverage is automatic for their patients for that drug||Prescriber automatically has coverage for their patients for the drug, based on prescriber specialty|
|Coverage is linked to Personal Health Number (PHN)||Coverage is linked to prescriber ID||Coverage is linked to prescriber ID|
The limited coverage criteria for each drug specifies whether a CPA or Practitioner Exemption affects how coverage is assigned.
Each limited coverage drug has a web page with medical criteria and other important information. The pages are accessed from the list of limited coverage drugs.
Dosage, strength, and form are listed first. Medical criteria for coverage follow in a standard table. Practitioner Exemptions and CPAs, if available, are listed below the patient medical criteria table.
Patients must meet the stated medical criteria for coverage to be approved. When a SA request is required – if there is no prescriber exemption or CPA, or if the prescriber is not able to act under either if present – a prescriber must submit detailed information to PharmaCare that demonstrates the patient meets the medical criteria.
A Practitioner Exemption means that all prescribers registered under the identified specialty do not need to submit SA requests for their patients for that drug. Practitioner exemptions are automatic; prescribers do not need to apply.
Some prescribers can sign a CPA for some limited coverage drugs. While the agreement is in place, the prescriber does not need to submit a SA request for their patients to receive coverage for the drug.
CPAs and Practitioner Exemptions are tied in PharmaNet to the prescriber’s ID. This means that 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 may not have coverage for that drug.
If a patient does not appear to have coverage for a limited coverage drug, check the patient’s PharmaNet profile and/or ask the patient for more information. If another prescriber, who you think would would likely be able to prescribe under a CPA or Practitioner Exemption, is identified, 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. (This is a new verbal order, overriding a non-specialist's prescription.)
Note: many Practitioner Exemptions automatically extend to subsequent prescribers. These are “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 HelpDesk.
CPAs were developed in consultation with Doctors of BC to save time for prescribers and patients and to streamline the SA request process.
When they enter a CPA, a physician agrees to
- follow the prescribing criteria; and
- allow PharmaCare to assess whether they’re satisfying the criteria; and
- annotate the prescription as needed.
PharmaCare has the right to require the renewal of a CPA or to discontinue a CPA if prescriptions are not consistent with limited coverage criteria.
CPAs and “Zero Cost” notes
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 CPA is in place and the patient is not adhering to 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 as 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.
Can Pharmacists Request a SA?
Under some circumstances, pharmacists may submit a request for a SA. These circumstances include situations in which the pharmacist is:
- acting as the prescriber (for instance, for OTC medications like acetaminophen or NRTs), or adapting for first-line ARBs or PPIs; or
- dispensing vancomycin following a hospital stay (see PharmaCare Newsletter 19-001); or
- working in a clinical setting, has access to the patient’s full medical record, and is working in collaboration with a prescriber.