Non-Insured Health Benefits (NIHB) Program's Short-Term Dispensing Policy

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The Non-Insured Health Benefits (NIHB) Program's Short-Term Dispensing (STD) policy was implemented on September 9, 2008, to establish compensation criteria for short-term fills of chronic use medications when it is medically necessary. This policy was implemented to address the significant increases in the frequency of short-term dispensing of chronic use medications that the Program had been experiencing. When short-term dispensing is medically necessary, the Program will compensate pharmacists up to one usual and customary dispensing fee every twenty-eight days, up to the regional maximum of the Program. If these medications are dispensed daily, the Program will compensate 1/28^th of the usual and customary dispensing fee, up to the Program's regional maximum.

As of July 15, 2012, the STD policy was expanded to also include anticonvulsants, antidepressants, antipsychotics, benzodiazepines and stimulant medications. When short-term dispensing is medically necessary, the Program will compensate pharmacists up to one usual and customary dispensing fee every seven days, up to the regional maximum of the Program, for the aforementioned medications. If these medications are dispensed daily, the Program will compensate 1/7^th of the usual and customary dispensing fee, up to the Program's regional maximum. When these medications are dispensed less frequently than every seven days such as once a month, the pharmacy will be entitled to one full dispensing fee, up to the regional maximum of the Program.

The following are exceptions to the STD policy:

• Refills for intermittent treatment of a chronic disorder or refills of a medication which is prescribed to be taken on an "as needed" (PRN) basis. Note: Medications prescribed to be taken on an "as needed" (PRN) basis and dispensed chronically may be subject to audit and recovery.
• Prescriptions for dose changes.
• The following drug categories: opioids and anticoagulants.
• The following dosage forms: oral liquid, injectable and suppository.
• Refills or new prescriptions when prescribed/dispensed in accordance with a court order.

Although the expanded STD policy took effect on July 15, 2012, the claims processing system changes were in place on September 28, 2012. During this period, providers were required to modify the dispensing fees submitted to the Program in accordance with the expanded NIHB STD policy. Overpayments are subject to audit and recovery.

The NIHB Short-Term Dispensing (STD) Policy Overview

1. Does the short-term dispensing (STD) policy replace NIHB's 100-day supply policy?

No. With the implementation of the changes to the STD policy, it is the Program's expectation that most chronic use medications will continue to be prescribed in 100-day supplies and dispensed in 100-day intervals.

2. What is the NIHB short-term dispensing (STD) policy?

The NIHB STD policy establishes compensation criteria for dispenses of certain chronic use medications where short-term dispensing is medically necessary. The NIHB STD policy took effect on September 9, 2008 and was expanded on July 15, 2012 to include more drug categories.

The NIHB STD policy consists of two reimbursement models:

September 9, 2008 STD Policy

This policy applies to certain chronic use medications where short-term dispensing is medically necessary.

For these medications, the pharmacist may bill the Program once every 28 days for their full dispensing fee. If these medications are dispensed daily, the Program will compensate 1/28^th of this fee.

The system changes are in place for the policy implemented on September 9, 2008, and the dispensing fees are calculated automatically.

STD Policy Expanded on July 15, 2012

A new reimbursement model was introduced on July 15, 2012 for:

• Anticonvulsants;
• Antidepressants;
• Antipsychotics;
• Benzodiazepines; and
• Stimulants.

For these medications for which short-term dispensing is medically necessary, the Program will compensate up to one full dispensing fee every seven days, up to the regional maximum of the Program. If these medications are dispensed daily, the Program will compensate 1/7^th of this fee. When these medications are dispensed less frequently than every seven days, such as once a month, the pharmacist will be entitled to one full dispensing fee, up to the regional maximum of the Program.

3. What is a "full dispensing fee"?

A "full dispensing fee" is the pharmacist's usual and customary dispensing fee, up to the regional maximum of the Program.

4. Will the list of drugs that fall under the STD policy change over time?

Yes, these lists can be expected to change over time when new DINs (Drug Identification Numbers) come on the market. Any changes to these lists will be communicated via updates to the NIHB Drug Benefit List as well as in the quarterly NIHB Provider Newsletters.

5. What if it is a medication that the client has already received, but the client is new to the pharmacy?

The claim would be considered a "new prescription", since the pharmacist has not seen the client before. It is understood that additional work is required by the pharmacist when a client is seen for the first time.

6. What is the appropriate process when dealing with medications subject to the STD policy that have been lost or stolen?

The STD policy does not change how providers deal with lost or stolen medication.

1. The provider will need to use the appropriate Canadian Pharmacist Association (CPhA) intervention code in the claims processing system to override the reject message for "Fill Too Soon" in their pharmacy software system.
2. The provider must cite the reason why the prescription was refilled early. The reason for the "Fill Too Soon" refill cannot contravene any other NIHB Program policies.
3. To avoid the recovery of claims payment during the claims verification/audit process, proper documentation of any intervention is required. The provider should write and retain the following information for their records, such as directly on the hardcopy or in the electronic patient profile:
   • Date of the intervention;
   • Summary of the intervention by the pharmacist;
   • Documented communication with the physician, caregiver, and/or client; and
   • Reason for early refill (medication lost, destroyed, stolen, physician changed dosage, or client going out of town for a period greater than the days' supply remaining of the current refill).

7. If the physician writes a prescription for "daily dispense", is this sufficient documentation to allow for a full dispensing fee?

No. A prescription with directions to "dispense daily" or "daily dispense" does not change NIHB's STD policy. The STD policy sets out guidelines for how the NIHB Program will compensate pharmacists for dispensing certain chronic use medications. The dispensing frequency is at the discretion of the physician and pharmacist. However, compensation under the NIHB Program is based on Program policies.

The NIHB Short-Term Dispensing policy implemented on September 9, 2008

1. Which medications fall under this policy?

The NIHB STD policy establishes compensation criteria for dispenses of certain chronic use medications where short-term dispensing is medically necessary.

2. Is the pharmacy allowed to bill in slightly shorter intervals should that need arise (e.g. twenty-seven days)?

The dispensing fee paid will be reduced. In this case, the dispensing fee will be calculated according to the following formula:

3. What happens when the prescriber intends for a medication to be used as a "PRN" (as needed) medication?

The chronic use medications subject to this policy that are given in quantities less than twenty-eight days and used by the patient on an "as needed basis" will be treated as "new prescriptions". The dispensing frequency is at the discretion of the physician and pharmacist.  However, compensation under the NIHB Program is based on Program policies.

Medications prescribed to be taken on an "as needed" (PRN) basis and dispensed chronically will be subject to audit.

4. What if the prescriber requests compliance packaging for a client?

It is recognized that compliance packaging is necessary in certain circumstances to help ensure clients receive needed medications at the appropriate time. The NIHB Program recognizes that in situations where clients who, due to cognitive or other challenges, cannot safely manage a twenty-eight-day drug supply, compliance packaging, such as blister packs, may be an appropriate tool. In situations where a compliance aid is requested by the prescriber, a dispensing fee every twenty-eight days will be allowed, resulting in approximately thirteen dispensing fees per year.

5. How will the adjudication system monitor the STD policy?

As with all NIHB policies, provider billings are monitored for compliance and are subject to audit.

The Expanded Short-Term Dispensing (STD) Policy Implemented on July 15, 2012

1. How did NIHB's STD policy change on July 15, 2012?

Effective July 15, 2012, the NIHB STD policy was expanded to include the following drug categories:

• Anticonvulsants;
• Antidepressants;
• Antipsychotics;
• Benzodiazepines; and
• Stimulants.

Under this expanded policy, the Program will compensate pharmacists up to one full dispensing fee every seven days, up to the regional maximum of the Program. If these medications are dispensed daily, the Program will compensate 1/7th of this fee. When these medications are dispensed less frequently than every seven days, such as once a month, the pharmacy will be entitled to one full dispensing fee, up to the regional maximum of the Program, every month.

2. Which medications fall under this expanded policy?

Effective July 15, 2012, the following drug categories are included: anticonvulsants, antidepressants, antipsychotics, benzodiazepines, and stimulants.