Alberta.ca » Income and Employment Supports Policy Manual


Health Benefits Card Coverage

Published Date: January 15, 2013
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07 High Volume Drug Use

POLICY

Prescription drug benefits are monitored by Alberta Blue Cross (ABC) and clients who meet established criteria, indicating potential prescription drug misuse, are identified on the monthly High Drug Utilization Report.

Workers must then review the client’s circumstances and determine if the client has a valid medical reason (complex illness such as cancer or HIV infection) for requiring a number of doctors and prescriptions. If the worker’s decision is that drug benefits are being misused, then the client’s prescription drug service must be restricted to one pharmacy (steps on how to restrict a client to one pharmacy can be found in the link below). ABC will then only accept claims from the drug store the client uses first in that benefit period.

Alerts

High Drug Utilization Reports are created for use by Income Support and are produced on a monthly basis (approximately by the 11th working day of the month). New monthly reports cannot be accessed until after the 10th working day of the month.

The monthly reports are for investigation and action for clients at respective worksites for a 3-month period.

  1. Alert Summary – Identifies clients who, based on their drug utilization, have a high probability for drug misuse.
  2. Claims Profile – This report provides client details on prescription drugs dispensed, drug quantity, name of pharmacy, name of physician, etc. This report could be used as a resource when speaking with the client.


The information on these reports is gathered by Alberta Blue Cross and identifies clients who have a high potential for drug misuse. The reports are driven by an ‘Alert’ system which recognizes the probability of drug misuse. An ‘Alert’ indicates there is potential drug misuse by the client during the reporting period. In general, the higher the total number of ‘Alerts’, the greater the probability that misuse is occurring.

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

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

  • Worksite
  • Unit and Caseload 
  • Client category 
  • File number 
  • Client name and birth date 
  • What triggered the alerts
  • Number of alerts 
  • Type of alerts


A supplementary list is attached which details:

  • Date of service
  • Drug product name 
  • Drug class 
  • Drug quantity 
  • Day supply 
  • Cost 
  • Pharmacy 
  • Physician


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

Report Generation Procedure Link

Please note, the High Drug Utilization reports used to be mailed to the District Offices by Alberta Community and Social Services every month. This process has now been automated so that the existing reports can be distributed automatically to the required locations in each DO.

Instructions on how to access the reports can be found using the following link: High Drug Utilization Reports

PROCEDURE

The High Drug Utilization Report is used as a review and assessment tool for workers. Unless the worker is aware of a valid reason why the client appears to be over-utilizing prescription drugs, drugs should be restricted on the 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. If 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.

To restrict prescription drug 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:
    • Prescription drug coverage has been restricted on their HBC because of high volume prescription drug 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.
  5. Forwards the High Drug Utilization Report to the Unit Administrative Support.


An HRE 1976 Drug Authorization will be used for restriction purposes 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 identified on the High Drug Utilization Report have had their prescription drugs restricted unless it is clear the client’s drug use is warranted.
  • Respond to inquiries made by clients on the restriction. 
  • Complete the Administrative Review for those clients who appeal.


Appeals

When clients submit a HRE 547 Notice of Appeal an Administrative Review is completed. When the client provides information from a physician indicating the client’s high use of prescription drugs is warranted, the supervisor may decide not to restrict prescription drugs.

When the Administrative Review decision is that prescription drug restriction is warranted, and the client wants to proceed to an appeal panel hearing, the supervisor may consult with the IS Specialist or a HQ Health Benefits Planner. Information provided by the High Drug Utilization Report should be presented at the appeal hearing.

Removing Restrictions

Existing Clients:
If a client wants the prescription drugs restriction lifted, it is their responsibility to ask their worker to review the restriction. When such a request is received, the supervisor consults the IS Specialist. The IS Specialist requests the ad hoc report from ABC in order to determine whether the client’s behavior has changed and a decrease in the volume of prescription drugs has occurred.

If no change has occurred, the restriction continues. If the volume has decreased and the client no longer meets the established criteria, the supervisor may 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 had restricted prescription drug coverage may have unrestricted coverage re-instated if their file is reopened after three months.

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