Frequency of dispensing and payment policy

This policy applies to all individuals enrolled in the NB Drug Plans, which includes the New Brunswick Prescription Drug Program (NBPDP), New Brunswick Drug Plan (Plan D) and other government sponsored programs, including the Extra-Mural Program (Plan W). 

This policy applies to all claims for drugs in solid oral dosage form taken on a continuous basis. Continuous drugs are defined as those that treat long-term conditions such as high cholesterol, high blood pressure or diabetes. Drugs prescribed to be taken on an ‘as needed’ basis and dispensed continuously are also included. 

Drugs used for the treatment of opioid use disorder, which are subject to dispensing requirements outlined in the New Brunswick College of Pharmacists Opioid Agonist Treatment Practice Directive (e.g., buprenorphine/naloxone, slow-release oral morphine) are excluded from this policy.

How often a prescription is dispensed is determined by the pharmacist, in collaboration with the patient and other health care providers involved in the patient’s care. Drugs taken continuously should be dispensed in a days’ supply which is appropriate for the product and the patient, up to 100 days at a time. 

Purpose of policy

This policy limits the payment of dispensing fees for drugs dispensed more frequently than every 28 days. If the criteria for payment of a dispensing fee under the policy are not met, pharmacies are only eligible for partial dispensing fees (no more than one dispensing fee every 28 days). 

Pharmacies are eligible for one dispensing fee per claim for drugs dispensed in a 28 to 100 days’ supply. For most patients, drugs taken continuously can be dispensed in a 100 days’ supply.

Dosage changes: Pharmacies are eligible for two dispensing fees in 28 days if the claim for the new dose of an existing drug is within 28 days of the previous claim.

Schedule changes: Pharmacies may submit claims earlier than required to accommodate statutory holidays, patient vacations or other scheduling issues. However, over an 84-day period, pharmacies are only eligible for three dispensing fees for drugs taken continuously.

For individuals living in facilities (includes nursing homes, adult residential facilities and correctional facilities) pharmacies may submit two claims and are eligible for a 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). 

Individuals living in facilities

Facilities include 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. Pharmacies are not eligible for additional dispensing fees, regardless of whether daily, weekly or other more frequent dispensing was prescribed. 

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 (e.g., one quarter fee every seven days) for patients who receive more frequent dispensing without any special documentation.

For pharmacies to be eligible for more than one dispensing fee every 28 days, specific criteria must be met, and documentation is required:

1. Dispensing drugs in a seven 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) 
     
2. Dispensing drugs in a one to six days’ supply. For a pharmacy to be eligible for more than one quarter (1/4) 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 
       

Drugs dispensed in a 28 to 100 days’ supply

Refer to Pharmacy claim submissions.

Drugs dispensed in a one to 27 days’ supply that are eligible for additional dispensing fees

Claims must be submitted with the CPhA Intervention Code “ER” and must meet the applicable criteria.

Drugs dispensed in a one to 27 days’ supply that are NOT eligible for additional dispensing fees

Claims for drugs that are typically taken to treat long-term conditions (e.g., high cholesterol, high blood pressure or diabetes) that are billed for less than a 28 days’ supply will be rejected by the claim adjudication system.

However, the system cannot identify all situations for which a drug is used continuously. Claims for drugs that are typically taken for a short period of time but are being taken continuously (e.g., long-term corticosteroid therapy, antibiotic prophylaxis) will not be rejected by the claim adjudication system, but the policy applies.

To comply with the policy, pharmacies may need to submit a zero or partial dispensing fee for certain claims:

• Weekly dispensing (seven days’ supply): Claims must be submitted using “P” in the special services code field, a day supply of “7” and a claim for a maximum payment of one quarter of the applicable dispensing fee
• One to 27 days’ supply dispensing (excluding seven days’ supply): Claims must be submitted with the CPhA Intervention Code “ER” using one of the following options:
  1. Claims must be submitted with a partial dispensing fee, calculated by dividing the applicable dispensing fee by 28 and then multiplying by the number of days’ supply being submitted. Example:
     1. Claims submitted for a 10 days’ supply must be submitted with a dispensing fee of $3.93 if applicable dispensing fee is $11 ($11 divided by 28 and multiplied by 10).
     2. Claims submitted for a 14 days’ supply must be submitted with half of the applicable dispensing fee.
  2. One claim in a 28-day period, or three claims in an 84-day period, can be submitted with the applicable dispensing fee. Any other claims within those periods must be submitted with a zero-dispensing fee. Examples:
     1. Claims submitted for a five days’ supply: One claim can be billed with the applicable dispensing fee and five claims must be submitted with a dispensing fee of zero over a 28-day period.
     2. Claims submitted for a 21 days’ supply: Three claims can be billed with the applicable dispensing fee and one claim must be submitted with a dispensing fee of zero over an 84-day period.

Resubmission of rejected claims

If a claim is rejected, it can be re-submitted using the CPhA Intervention Code “ER” with the applicable dispensing fee for any of the following reasons:

• new drug starts
• dosage changes
• drugs that are not taken continuously (e.g., acute use, as needed)
• accommodation for holidays
• extemporaneous preparations (compounds)
• criteria for additional dispensing fees are met

A hard copy of the prescription is sufficient documentation to support reimbursement of dispensing fees for the following types of claims:

• new drug starts
• dosage changes
• drugs that are not taken continuously
• accommodation for holidays

For drugs dispensed in a one to 27 days’ supply that meet criteria for additional dispensing fees, a frequent dispensing form must be completed for each patient:

• Frequent Dispensing Documentation Form for 7 to 27 Days’ Supply (PDF 558 KB)—must be completed every year for drugs dispensed in a seven to 27 days’ supply
• Frequent Dispensing Documentation Form for 1 to 6 Days’ Supply (PDF 548 KB)—must be completed every six months for drugs dispensed in a one to six days’ supply

Pharmacists may include more than one drug per form. A new form is required for a new drug started after a form has been completed and dated. 

Forms do not need to be sent to the New Brunswick Drug Plans, but they must be retained for the period specified in the New Brunswick Pharmacy Act and related bylaws.

All claims submitted for reimbursement are subject to audit and recovery. 

Completed forms must be retained on file by the pharmacy and readily available for audit purposes. The NB Drug Plans will not accept Frequent Dispensing Documentation forms completed after a pharmacy has been notified of an audit.