PAS Public Site

Green Shield Canada

Green Sheild Canada

The online adjudicator for green shield Canada is ProviderConnect.

Most information and questions pertaining to their policies can be found
in the ProviderConnect pharmacy provider guide. As well, a link to
their pharmacy provider website can be found here.

Maintenance Medication Fill Limits Policy


Update: Green Shield Canada Days Maintenance Medication Fill Limits – Feb 4, 2016

Dear Members:

On February 1, 2016, Green Shield Canada  (GSC) limited the number of fills to five per year for a defined list of maintenance drugs . See complete information below from a previous PAS correspondence. Several questions and issues have arisen since the implementation of the policy. We have spoken to GSC and based on our conversations, our current understanding of the subtleties of the policy will be addressed in the below Q & A format.

  1. My patient has other drug coverage (either Saskatchewan Health or another third party payor), in addition to GSC. Do I have to dispense 90 days of maintenance drugs in order for their GSC coverage to adjudicate?

A: No. If any dollar amount of the maintenance drug(s)is covered by another primary payor (either Saskatchewan Health or another third party payor), GSC will accept and pay for the adjudication at less than 90 days, even if that drug(s) is on their maintenance drugs list. This will be the case only when the other payor covers an amount and the claim is adjudicated before GSC is adjudicated.

  1. My patient has other coverage (either Saskatchewan Health or another third party payor), but they have to reach a deductible before that coverage kicks in. Is a 90 day dispense of maintenance drugs required in order for GSC coverage to adjudicate?

A: Yes. GSC does not recognize a deductible that has not yet been reached as a form of coverage, and as such 90 days of a maintenance drug(s) must be dispensed in order for the patient to receive GSC coverage.

  1. My patient needs an Interim Supply, and they only had one month of a   maintenance drug last time. Will GSC cover one month of a maintenance drug if a pharmacist prescribes?

A: When a pharmacist is not able to reach a practitioner for an additional 90 day supply, GSC will accept a one month maintennce drug Interim Supply prescription by a pharmacist with an intervention code.  Be sure to document in the case of audit.

  1. My patient has two refills left on their prescription. How can they receive GSC coverage?

A: When a pharmacist is not able to reach a practitioner for an additional 90 day supply, GSC will accept the total amount remaining if it is less than a 90 day supply with an intervention code. Be sure to document in the case of audit.

  1. If a practitioner continues to prescribe for less than 90 days  for maintenance drugs, how can a patient receive GSC coverage?

A: For patients that may require more frequent dispensing, due to a cognitive impairment or other issue, pharmacists will be required to submit a form (available on GSC’s providerConnect website) outlining the clinical rationale supporting the request. GSC’s pharmacy team will review, and where appropriate, grant an exemption to the policy.

  1. Where do I find intervention codes?

A: At the top of the maintenance drugs list, there are three intervention codes noted.

  1. My patient is a complex patient on several drugs and a 90 day supply just isn’t possible for them because of all of frequent changes. How can they get GSC coverage?

A: GSC has several exception to 90 day policy on maintenance drugs including and accounting for:

  • Recogniz(ing) certain drugs that are taken chronically but should not be dispensed in large quantities (e.g., antipsychotic agents).
  • If the plan member is on five or more maintenance drugs, less than a three-month supply will automatically be allowed by the system.
  • For any new prescriptions for maintenance medications, the initial dispensing quantity will still be limited to a 30-day supply to provide you with an opportunity to properly assess patient tolerance of the drug. Once tolerance is established, the GSC system will force all future refills to be dispensed in a three-month supply.
  • For patients that may require more frequent dispensing, due to a cognitive impairment or other issue, pharmacists will be required to submit a form (available on GSC’s providerConnect website) outlining the clinical rationale supporting the request. GSC’s pharmacy team will review and where appropriate grant an exemption to the policy.
  1. How can I get more information on this policy?

A: In addition to the bulletin sent to pharmacies about this change found at https://www.providerconnect.ca/AdminContent/Forms.aspx?type=pharmacy, GSC is creating a communication with more information addressing frequently asked questions and it will be sent to pharmacies shortly.

Green Shield Canada Days Maintenance Medication Fill Limits – Feb 1, 2016

Dear Members:

As you may be aware, effective February 1, 2016, Green Shield Canada  (GSC) has limited the number of fills to five per year for a defined list of maintenance drugs. A general overview was sent out also in October 2015 and is contained in our October 2015 Pharmacy update and the information is contained on their website at providerConnect at https://www.providerconnect.ca/AdminContent/Forms.aspx?type=pharmacy

For a complete list of the drugs on the Maintenance List go to https://www.providerconnect.ca/Carriers/GreenShield/Pharmacy/PharmacyManuals/en_CA/GSCMaintenanceMedicationFillLimit.pdf Please note there are several exceptions to this policy as noted below.

A passage about this policy from the GSC October 2015 update as follows:

“ Maintenance Medication Fill Limits: what you need to know

Effective February 1, 2016, GSC will limit the number of fills to five per year for a defined list of maintenance drugs. To accomplish this, GSC will be denying claims that are dispensed for less than a three-month supply of the applicable drugs; the response code from the GSC system for these claims will be: “DR = days supply lower than minimum allowable”.

To accomplish this, GSC will be denying claims that are dispensed for less than a three-month supply of the applicable drugs; the response code from the GSC system for these claims will be: “DR = days supply lower than minimum allowable”. A complete list of the drugs included in this new reimbursement policy will be published on GSC’s providerConnect website.

Why are we doing this?

Most common maintenance medications are prescribed for a three-month supply, with multiple refills. However, a recent analysis of GSC data has revealed a growing trend towards monthly dispensing of these maintenance medications. This can lead to patient inconvenience, reduced overall adherence to medication therapy and increased drug plan costs.

Exceptions

Similar to GSC’s current Compliance Packaging Policy, the system is set to recognize certain drugs that are taken chronically but should not be dispensed in large quantities (e.g., antipsychotic agents). Also, if the plan member is on five or more maintenance drugs, less than a three-month supply will automatically be allowed by the system.

For any new prescriptions for maintenance medications, the initial dispensing quantity will still be limited to a 30-day supply to provide you with an opportunity to properly assess patient tolerance of the drug. Once tolerance is established, the GSC system will force all future refills to be dispensed in a three-month supply.

For patients that may require more frequent dispensing, due to a cognitive impairment or other issue, pharmacists will be required to submit a form (available on GSC’s providerConnect website) outlining the clinical rationale supporting the request. GSC’s pharmacy team will review and where appropriate grant an exemption to the policy.”

Even though PAS does not negotiate contracts with GSC, we expressed our concerns to them about this type of change, its impact on patients and drug wastage as well as the differences in provincial days’ supply policy.   This and other issues of this nature continues to be a concern of ours and of pharmacists across the country. As such, CPhA has an advocacy working group of representatives from the profession that works directly with insurance groups that each province can feed into. Issues such as this are discussed at that table, along with a larger value proposition and education of pharmacy services and associated patient outcomes. PAS will continue to advocate for and pass along provincial issues along with the larger national context about patient and pharmacy impacts of policy changes such as these to our national representative working group.