Individuals living in facilities - includes nursing homes, adult residential facilities, and correctional facilities
Except for new drug starts and dosage changes, pharmacies that dispense drugs on a weekly, bi-weekly, or another schedule are only eligible for partial dispensing fees (see the Claim Submission section below.) Pharmacies are not eligible for additional dispensing fees regardless of whether daily, weekly or other more frequent dispensing was prescribed or requested.
Pharmacies may submit two claims and are eligible for a partial dispensing fee on each claim, when the same drug and strength is prescribed to be taken continuously and as needed (e.g., lorazepam 1 mg three times daily and 1 mg at bedtime as needed).
Pharmacies are eligible for two dispensing fees in 28 days in the following instances:
- New drug* starts: if the initial claim is for less than a 28 days’ supply and a subsequent claim for the same drug is dispensed within the first 28 days.
- Dosage changes: if the claim for the new dose of an existing drug is within 28 days of the previous claim.
* New drugs are those which have not been taken in the last 12 months. The adjudication system does not generate an electronic message to pharmacies if the patient has had the drug in the last 12 months. Pharmacists must confirm if the patient has taken the drug in the last 12 months.
Individuals not living in facilities
Pharmacies are eligible for two dispensing fees in 28 days in the following instances:
- New drug* starts: if the initial claim is for less than a 28 days’ supply and a subsequent claim for the same drug is dispensed within the first 28 days.
- Dosage changes: if the claim for the new dose of an existing drug is within 28 days of the previous claim.
* New drugs are those which have not been taken in the last 12 months. The adjudication system does not generate an electronic message to pharmacies if the patient has had the drug in the last 12 months. Pharmacists must confirm if the patient has taken the drug in the last 12 months
Pharmacies may bill partial dispensing fees for patients who receive more frequent dispensing without any special documentation (e.g., ¼ fee every 7 days.) See the Claim Submission section below.
For pharmacies to be eligible for more than one dispensing fee every 28 days, specific criteria must be met, and documentation is required as outlined below:
a) Dispensing fee for drugs dispensed in a 7 to 27 days’ supply:
The patient’s drug therapy cannot be managed when dispensed as a 28-day supply and at least one of the following patient factors must apply:
- Risk of drug misuse, abuse, or diversion
- Failed to comply with a drug regimen dispensed in a 28-day compliance package due to cognitive impairment, mental disability, psychiatric illness or physical disability
- No fixed address and are susceptible to theft or loss of belongings
- Requires frequent laboratory tests for therapeutic drug monitoring (e.g., clozapine)
Pharmacy Documentation Requirements are outlined below.
b) Dispensing fee for drugs dispensed in a 1 to 6 days’ supply:
For a pharmacy to be eligible for more than one quarter (¼) of a dispensing fee every 7 days,
- the drug must have a high potential for dependence, misuse or abuse (drug must be in one of the following categories: narcotic, controlled drug, benzodiazepine or other targeted substance, anticonvulsant, antidepressant, antimanic, antipsychotic or hypnotic), and
- the patient’s drug therapy cannot be managed when dispensed as a 7-day supply, and
- at least one of the following patient factors must apply:
- Risk of intentional overdose
- History of drug misuse, abuse, or diversion
- Severe cognitive impairment, severe mental disability, severe psychiatric illness or severe physical disability
Pharmacy Documentation Requirements are outlined below.