Pharmacy Policy (General)

Transcription

1 WORKSAFE VICTORIA Pharmacy Policy (General) WorkSafe can pay the reasonable costs of medications and other pharmacy items required as a result of a work-related injury or illness in accordance with Victorian workers compensation legislation (the legislation). This excludes items covered in the WorkSafe Aids and Appliances Policy (for example, crutches). Specific policies WorkSafe has a number of specific medication policies. These have been developed on the basis of: the best available clinical evidence or recognised best practice as accepted by the health industry, to guide and promote quality healthcare for injured workers current health industry standards as reflected in manufacturer s guidelines, product information and recommended dosages alignment with similar organisations, including the Victorian Transport Accident Commission. The policies are: Drugs of Dependence (Schedule 8 and Schedule 4 medications) Erectile Dysfunction Glucosamine Sedatives Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). Who can provide medication and pharmacy items to injured workers? WorkSafe can pay for medication and other pharmacy items dispensed by pharmacists who are: registered with WorkSafe to provide pharmacy services, and registered with the Pharmacy Board of Victoria, or the equivalent in other Australian states or territories. Pharmacies are required to register with WorkSafe to obtain a WorkSafe provider number to enable payment of invoices. If the pharmacy name or address details change, a new provider number will need to be allocated. Your updated details should be faxed to the Provider Registration Branch of WorkSafe on (03) A letter with the new provider number will be mailed to the pharmacy address supplied. What medications can WorkSafe pay for? WorkSafe can pay for the reasonable costs of medications that are: required as a result of a work-related injury or illness requested by a registered medical practitioner or registered dentist provided by a registered pharmacist provided in accordance with the Pharmaceutical Benefits Scheme (PBS), where clinically appropriate and available, or in accordance with the WorkSafe requirements for non-pbs and over the counter medications. Please refer to for more information registered (not listed) in the Australian Register of Therapeutic Goods (ARTG). What medications will WorkSafe not pay for? WorkSafe cannot pay for medications that: do not relate to a work-related injury or illness are not provided on the request of a registered medical practitioner or registered dentist are not provided by a registered pharmacist Note: This policy is a guideline issued by WorkSafe Victoria under Victorian workers compensation legislation in respect of the reasonable costs of services, and services for which approval should be sought from the WorkSafe Agent or self-insurer (as the case may be) before the services are provided. WSV1560/04/05.13

2 are not provided in accordance with the PBS or the WorkSafe requirements for non-pbs and over the counter medications have no National Health and Medical Research Council level 1 or 2 evidence that the medication is safe and effective. Refer to the Non-established, New or EmergingTreatments and Services Policy are recommended by a healthcare provider other than a registered medical practitioner or registered dentist are prescribed as part of a clinical trial were required prior to the work-related injury or illness, unless the dose levels increase as a direct result of the work-related injury or illness, or are not invoiced according to WorkSafe s Pharmacy Invoicing Requirements. Are injured workers entitled to Pharmaceutical Benefits Scheme (PBS) medications? All injured workers with a Medicare Card are entitled to PBS prescribed medications. All medications should be prescribed under the PBS where clinically appropriate and available. For PBS prescribed medications, WorkSafe will reimburse all patient contribution charges set out in the PBS, including brand and therapeutic premiums. Where a medical practitioner or dentist prescribes a dosage over the PBS limit for prescribed medications an authority from Medicare Australia is required. For more information on the entitlements of injured workers to PBS prescribed medications, please visit the Medicare Australia website at Are injured workers entitled to claim non-pbs (privately prescribed) medications? Medications should be prescribed under the PBS when clinically appropriate and available. WorkSafe can pay for non-pbs (privately prescribed) medications if the WorkSafe Agent is satisfied that the medications are clinically appropriate for the work-related injury or illness and there are no readily available alternatives on the PBS. For non-pbs private prescription items, the WorkSafe Agent can pay a mark-up of: Wholesale price 1 Mark-up Dispensing fee Less than $100 Up to 60% $7.50 Between $100 and $400 Up to 25% $7.50 Greater that $400 Up to 10% $7.50 There will be no further use of Arrow pricing. 1 Where there are multiple units of the product being supplied, the wholesale cost for mark-up purposes will be the total cost of quantity supplied. The dispensing fee for narcotic medications (Schedule 8) is $ For more information please see WorkSafe s Drugs of Dependence Policy, which states that funding for these medications outside the PBS will be considered in exceptional circumstances only. Can WorkSafe pay for complementary medications? Complementary medications include vitamins, minerals, herbal remedies and nutritional supplements. WorkSafe can pay the reasonable costs of complementary medications which are: required as a result of a work-related injury or illness registered (as opposed to listed) in the Australian Register of Therapeutic Goods (ARTG) by the Therapeutic Goods Administration Branch of the Commonwealth Department of Health and Ageing - for exceptions to this policy, refer to Glucosamine Policy. supplied by a registered pharmacist, and supported by a written clinical rationale from a registered medical practitioner or dentist.

3 Healthcare providers other than a registered medical practitioner or registered dentist are not approved by WorkSafe to provide complementary medications. WorkSafe Agents can pay a registered pharmacist up to 50% above the wholesale price of complementary medications. Can WorkSafe pay for Over-the-counter items? Over-the-counter (OTC) items include medications and non-drug pharmacy items and can be sold by a pharmacist without a prescription, for example, analgesics and laxatives, dressings, bandages, supports and syringes. (For information on complementary medications, refer to Can WorkSafe pay for complementary medications section of this policy) OTC items are not covered in the WorkSafe Aids and Appliances Policy. WorkSafe can pay the reasonable costs of OTC medications required as a result of a work-related injury or illness that are: registered (as opposed to listed) in the Australian Register of Therapeutic Goods (ARTG) by the Therapeutic Goods Administration Branch of the Commonwealth Department of Health and Aged Care supplied by a registered pharmacist, and requested by a registered medical practitioner or dentist. WorkSafe can pay the reasonable costs of non-drug pharmacy OTC items (e.g. wound dressing products, bandages, dressings) required as a result of a work-related injury or illness that are: supplied by a registered pharmacist, and requested by a registered medical practitioner or dentist. The WorkSafe pricing policy regarding the reasonable costs of OTC items is in accordance with the following: NDPSC 1 classification Mark-up 2,3 Dispensing fee 4 No classification, or Schedule 2 Up to 50% above the wholesale price None Schedule 3 (Pharmacist Only) Up to 75% above the wholesale price None 1 National Drugs and Poisons Scheduling Committee (NDPSC), administered by the Therapeutic Goods Administration 2 Mark-ups are exclusive of GST, which may be added to the marked up price where applicable 3 Where there are multiple units of the product being supplied, the wholesale cost for mark-up purposes will be the total cost of quantity supplied 4 Dispensing fees are not paid for OTC items supplied by a pharmacist that are not on the PBS, as this is not considered to be a reasonable cost If a doctor prescribes an OTC item listed on the PBS, the pharmacist is entitled to dispense the item through the PBS and invoice the WorkSafe Agent for the patient contribution. WorkSafe may request Pharmacists to produce documentation (the request from a medical practitioner or registered dentist) supporting the invoicing of OTC items to treat injured workers. For OTC items a copy of a prescription is not required, however all items must be requested by a medical practitioner and be required for treating the work -related injury or illness. Requests can be in the form of a prescription or message on letterhead requesting the OTC medication or item. This is to be kept on file at the pharmacy. Restrictions to the funding and supply of medications a) Maximum Therapeutic Dose WorkSafe can pay for medications up to the maximum therapeutic dose as determined by the manufacturer. This dose is considered to be the quantity and frequency recommended in the consumer product information. WorkSafe can pay for medications over the maximum therapeutic dose if:

4 a written request is provided by a prescribing medical practitioner or dentist the request is clinically justified, and prior approval has been obtained from the WorkSafe Agent. This applies to both OTC and prescription medication. Where a medical practitioner prescribed a dosage over the limit for prescription medicines on the PBS, they must obtain an authority from Medicare Australia. Under these circumstances a private script will not be funded. Pharmacists must supply medications according to the registered medical practitioner or dentist's instructions with consideration of the manufacturer's recommended maximum therapeutic dose. b) Restrictions on Quantities Dispensed and Bulk Supply The WorkSafe Agent cannot pay for excessive quantities of medications except in exceptional circumstances, such as overseas travel. If a registered medical practitioner or dentist believes exceptional circumstances apply, a written clinical rationale must be provided to the WorkSafe Agent for consideration and approval prior to prescribing such medications. The maximum quantity of medications to be paid for cannot exceed 12 weeks. The prescription must be endorsed by the prescribing medical practitioner or dentist as per "Regulation 24" of the PBS Guidelines, for dispensing repeat quantities. This policy does not apply to Schedule 8 medications. Due to the inherent risks associated with these medications, Schedule 8 medications will not be paid to cover overseas travel or bulk supply. See WorkSafe s Drugs of Dependence Policy for further details. Pharmaceutical Benefits Scheme (PBS) The PBS is governed by the National Health Act 1953 and is similar to Medicare in that the Commonwealth Government covers a proportion of the cost of the drug or medicine with a small out of pocket cost to the patient. The payment to the pharmacist by the patient under this scheme is set by the Commonwealth Government and is called the co-payment. The Commonwealth Minister for Health and Ageing is responsible for identifying the drugs or medicines whereby the benefit applies as not all medicines are included in the scheme. For those drugs prescribed under the scheme WorkSafe reimburses the standard patient contribution charges. WorkSafe also reimburses PBS brand premiums if the prescriber has indicated on the prescription that brand substitution is not permitted. Australian Register for Therapeutic Goods (ARTG) Medications cannot be sold in Australia unless the Therapeutic Goods Administration (TGA) either registers or lists the product for marketing. Registered goods, which include prescription medicines, are evaluated for quality, safety and efficacy. Listed goods are assessed for compliance with standards relating to quality, safety, and manufacture. More information is available at: tga.gov.au WORKSAFE INVOICING REQUIREMENTS WorkSafe Agents require the following information in order to process the invoice: Payee details Patient details Medication details WorkSafe provider number Family name and given Date dispensed name(s) Pharmacy name Address For items billed under the Pharmaceutical Benefits Scheme (PBS), the PBS item code number Billing address Claim number if not known then patient s date of birth A copy of the original script for private script medications

5 Payment address (if different to billing address) Invoice number and date Total amount charged and date of accident or injury A copy of the repeat authorisation, where appropriate (for private medications only) Full description of item (including script number, brand name and medication form) Quantity of medication dispensed Medication strength (where applicable) Amount charged per item If the patient is a hospital patient, specify if medication prescribed is for outpatient or discharge Before submitting an account Before you submit an account to WorkSafe, please: ensure that your patient has an accepted WorkSafe claim remember that only one patient may appear on each account do not issue the WorkSafe Agent with receipts or patient history reports unless requested. Accounts should be in the form of a dispensary computer-generated tax invoice and must be addressed to the WorkSafe Agent. The status of an item for example, OTC, may be handwritten onto the tax invoice. How a worker is reimbursed for a pharmacy expense WorkSafe prefers that a pharmacist invoice the injured worker s employer or Agent. WorkSafe Agents can only pay for medications and items that have been approved by WorkSafe. WorkSafe Agents are only liable for the reasonable costs of items required for the treatment of a work-related injury or illness. If an injured worker chooses to pay an account at the time of service and seek reimbursement from the WorkSafe Agent of the reasonable costs of those items, they must provide a fully itemised receipt as proof of purchase. To assist the Agent in determining reasonable costs, an itemised tax receipt requires the following information: Pharmacy name and pharmacy address or WorkSafe provider number Worker s name, home address and /or claim number (this can be handwritten) Medication details: -Full name of medication or item (including brand name where possible) -Date dispensed or supplied -Status of medication (this can be handwritten) i.e. PBS (include the PBS code), private or OTC -Quantity of medication dispensed i.e. number of tablets -Strength of medication i.e. 5mg, 50mg, etc* -Medication form i.e. tablet or caplets, etc* -Total amount charged per item* -Total amount paid. * May not be required for non- drug pharmacy items. It is recommended that a worker ask their pharmacist for a dispensary computer-generated tax

6 receipt for dispensed medications/items which contains the above information, so that reimbursement can be processed correctly and efficiently. Please note that a register receipt may not contain all this information. Reimbursement will occur in line with WorkSafe s fee schedule. If a pharmacy charges above this rate any excess costs may be incurred by the worker. It is recommended that injured workers keep copies of all receipts for their records. If an injured worker has not been reimbursed within 30 days, then they should call their employer or their Agent. Further Information If you have a query about a specific item for payment on an invoice or remittance advice, please contact the relevant WorkSafe Agent. Information about WorkSafe policies can be found at worksafe.vic.gov.au or by contacting WorkSafe Advisory Service on freecall