5.10 Full Payment Policy

General Policy Description

Under the Full Payment Policy, pharmacies are not permitted to charge any amount directly to clients who are receiving full PharmaCare coverage for a claim.

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Policy details

When the Full Payment Policy applies

The Full Payment Policy applies to all pharmacy providers that submit claims to PharmaCare.

Pharmacies must not charge any amount directly to an individual receiving full PharmaCare coverage for a drug, substance, or related service that is a full benefit.

Individuals receiving full PharmaCare coverage are those covered under PharmaCare plans B, C, D, F, G, M, P, W, Z, and those that have reached their Fair PharmaCare family maximum.

A drug, substance, or related service is a full benefit when it is:

• A regular PharmaCare benefit (that is, no Special Authority required)
• A limited coverage drug for which Special Authority approval has been granted
• Not subject to any reimbursement limit on adjudication under the Low Cost Alternative program or Reference Drug Program

When the Full Payment Policy does not apply

The Full Payment Policy does not apply when the drug, substance, or related service:

• Is not a PharmaCare benefit
• Adjudicates as a partial PharmaCare benefit under the Low Cost Alternative program or Reference Drug Program
• Is exempt from the Full Payment Policy

The following products are exempt from the Full Payment Policy:

• Insulin
• Medical supplies and devices, including
  • prosthetics
  • orthotics
  • ostomy supplies
  • cystic fibrosis nutritional supplements/vitamins
  • diabetes supplies (insulin pumps and supplies, needles and syringes, continuous/flash glucose monitors and blood glucose test strips)

 This exemption does not include copper IUDs.

Charges in error

When a pharmacy provider mistakenly charges drug, substance, related service, or dispensing fee costs directly to an individual for a claim the Full Payment policy applies to, the pharmacy provider must refund those charges.

Procedures

When submitting claims that the Full Payment Policy applies to, do not charge clients for any amount in excess of that accepted for reimbursement by PharmaCare.

Policy in practice

For a client covered under several plans, the Full Payment Policy might not apply to all their prescriptions. For example, Roberto presents two prescriptions, one for a psychiatric medication covered under Plan G and the other for ointment covered under Fair PharmaCare. The claim for the psychiatric medication will be subject to the Full Payment Policy. Robert has met his Fair PharmaCare deductible but has not yet reached his family maximum, so the claim for the ointment will not be subject to the Full Payment Policy.

If a pharmacy provider is able to determine that the client’s private insurer will cover any costs in excess of the amount PharmaCare covers, they can charge the private insurer. The determination of coverage by the private insurer must be made at the time the product is dispensed. A pharmacy provider cannot charge a client on the understanding that a private insurer may pay all or some of the cost at a later date.