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Health Benefits Card Coverage

Published Date: January 30, 2020
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07 High Volume Drug Use

POLICY

Drug product benefits (prescriptions, nutritional products, etc) are monitored by Alberta Blue Cross (ABC) and clients who meet established criteria, indicating potential high drug product usage, are identified on the monthly High Drug Utilization Report - Alert Summary.

Workers review the circumstances of clients who are identified in the report and determine if the client has a reason for requiring drug products from several doctors and/or multiple pharmacies (e.g. complex illness, limited access to specialists in the region, or other practical difficulty obtaining all medications from one location).

If the worker’s decision is that there does not appear to be a rationale for requiring prescriptions from multiple sources, then the client’s drug product service may be restricted to one pharmacy. Clients who are restricted will only be able to obtain their drug products from one pharmacy each month. Claims at other pharmacies will not be accepted for coverage by the program.

Alerts

High Drug Utilization Reports are produced on a monthly basis (approximately by the 11th working day of the month) for Income Support staff. These reports can assist staff in managing files and ensuring clients’ needs are being addressed appropriately. The High Drug Utilization Report - Alert Summary page identifies clients who, based on their use of the Health Benefits Card have high drug product usage that triggers certain alert criteria.

An ‘Alert’ flags different volumes and types of prescriptions filled. Files with multiple alerts warrant consideration by the worker, unless the worker has prior knowledge of the client’s situation. The Alert Types are explained below:

Alert Types Table

Alert Type

Description

Maximum # of alerts over 3 month period

1

Identifies clients who are receiving drugs with a high potential for misuse and are getting these drugs from multiple doctors and/or pharmacies within a 1-month period.

Criteria: >8 claims for drugs with high abuse potential plus >4 prescribers or pharmacies in 1 month

6

2

Identifies clients who may be using an excessive amount of doctors or pharmacies in a 3-month period.

Criteria: Prescription claims from >9 prescribers or >6 pharmacies in a 3-month period.

2

3

Identifies clients who have a potentially high amount of drugs within one drug class and are getting these drugs from multiple doctors and/or pharmacies over a 3-month period.  Drugs dispensed on a daily basis will be excluded and anyone with 12 or less claims for the same drug (DIN).

Criteria: >20 claims within one drug class plus >4 prescribers or pharmacies in a 3-month period.

No maximum


High Drug Utilization Report - Alert Summary

Each month, Financial Operations produces the High Drug Utilization Report - Alert Summary from the ABC alerts listing. The report identifies:

  • District Office
  • Client category 
  • File number 
  • Client name and birth date 
  • Number of alerts 
  • Type of alerts

The report excludes clients that are already restricted to one pharmacy and clients with two or less Alert #1’s.

The High Drug Utilization reports are emailed to the District Offices every month. Workers and Supervisors are responsible for the procedures below.

PROCEDURE

The High Drug Utilization Report is used as a review and assessment tool for workers. If the worker is aware of a valid reason why the client appears on the report, no restriction is applied. In other cases, the client may be restricted to one pharmacy on their Health Benefits Card (HBC), commencing the next period of assistance.

  • The restriction remains in effect until the supervisor reviews the situation and removes the restriction. I
  • f the worker is aware of a valid reason for not restricting the client, the worker should clearly note the reason on the client’s file.
  • It is recommended to discuss the situation with clients before any restrictions are made.

To restrict drug product coverage on the HBC to one pharmacy, the worker:

  1. Changes the Health Benefits Card (Med Code) field in Client File function 7 from 6 to 9 to indicate Health Benefits, Standard Dental, Restricted Drugs. The HBC will be printed with “R-Drugs” on it when the 9 code is entered.
  2. Informs the client that:
    • Drug product coverage has been restricted on their HBC because of high volume Drug product use.
    • They are restricted to one pharmacy of their choice.

      Note
      For clients who cannot be contacted by phone, the following message is put on their cheque: “Drug coverage will be restricted to one pharmacy of your choice.”
  3. Records in comments on the client’s file the reason for restricting drug coverage.
  4. Places alert 02 Health Concerns on CCD.


An HRE 1976 Drug Authorization is used for restricted files only when the client moves and cannot use the original pharmacy, the pharmacy closes, or the client requires prescriptions in another centre due to travel to obtain health services.

The supervisor is responsible to:

  • Ensure those clients situations identified on the High Drug Utilization Report have been reviewed to consider whether it would be appropriate to restrict coverage to one pharmacy.
  • Respond to inquiries made by clients about placing/removing the restriction.


Removing Restrictions

Existing Clients:
If a client wants the drug product restriction lifted, it is their responsibility to ask their worker to review the restriction. When such a request is received, the supervisor consults with Delivery Supports.

  • Delivery Supports can request the ad hoc report “AEI Claims Profile” in order to determine whether the client’s situation has changed and whether a decrease in the volume of drug product has occurred.
  • If the volume of drug product use has decreased or if the circumstances have otherwise changed, the supervisor may decide to remove the restriction.

When prescription drugs are removed from restriction on the HBC, the worker changes the Health Benefits Card (Med Code) field in Client File to 6.

Re-opened Files:

Clients whose files subsequently close and who have previously had restricted drug product coverage have unrestricted coverage re-instated if their file is reopened after three months.

If a client’s file is reopened within three months, they continue to have restricted drug product coverage.