Summer 2018: Ask the Expert

August 21, 2018 The Tablet

Can pharmacists process claims for over-the-counter (OTC) / Schedule II items under a pharmacist’s license without the need for a prescription?

Under the Pharmacy Operations and Drug Scheduling Act’s Drug Schedules Regulation, a Schedule II item is defined as “…drugs which may be sold by a pharmacist on a non-prescription basis and which must be retained within the Professional Service Area of the pharmacy where there is no public access and no opportunity for patient self-selection.” 

While a Schedule II item does not require a prescription by definition, this does not necessarily mean that an electronic claim for a Schedule II item will be accepted by all payers, as some payers will have their own policies which must be adhered to. 

Our general guidance is that for claims through PharmaCare, pharmacists may process claims under their own license for Schedule II drugs. For private third party payer claims, it is not recommended at this time.

The Public Payer

The procedure for processing non-prescription items through PharmaCare is detailed in the PharmaCare policy manual section 3.7. This section spells out PharmaCare’s policy and acceptance of claims for OTC items under a pharmacist’s license.

Using Practitioner IDs for non-prescription items

  • When submitting claims for non-prescription products, pharmacists may enter their Pharmacist ID in place of the Practitioner ID. If a pharmacist elects to use the Practitioner’s ID, the pharmacist must obtain authorization from the practitioner to dispense the item.
  • Pharmacists may also need to use their Pharmacist ID in place of a Practitioner ID under other circumstances. For instance, the Pharmacist’s ID would be used for:
    »  Claiming non-prescription items eligible for PharmaCare coverage

Private Payers

Each payer will have their own specific policies around claim submission, though not all of them refer to requirements for Schedule II item claims. For claims through third party payers, our interpretation is that the validity of the claim is contingent on it being based on a prescription from an authorized prescriber, as seen in the excerpts below taken from the TELUS Health and Pacific Blue Cross pharmacy manuals:

TELUS Health Pharmacy Manual (2018) (pg. 19)
Authorization for prescriptions:

  • TELUS Health requires an authorized prescription for claims submitted electronically. This includes both prescription items and over the counter (“OTC”) items. An authorized prescriber can order a prescription. TELUS Health considers authorized prescribers to be as follows: physician, surgeon, dentist or other healthcare professional prescriber* in good standing with their governing body. Any provincial restrictions placed on prescribing practices are followed by TELUS Health (e.g. a specific list of drugs that a practitioner can prescribe from).
    *where provincial laws permit these persons to prescribe.

Pacific Blue Cross – Pharmacy Reference Guide (Jan.2018) (pg.17)

  • Pacific Blue Cross will accept pharmacist authorized prescriptions for test strips and other non-prescription requiring diabetes supplies, as long as the prescription authorization is within the scope of practice for the pharmacist.

Both excerpts above will accept claims under a pharmacist license if provincial laws permit pharmacists to prescribe. 

Under section 1 of the Pharmacy Operations and Drug Scheduling Act (PODSA):
“prescription” means an authorization from a practitioner to dispense a specified drug or device for use by a designated individual or animal;
“practitioner” means a person
(a) Who is authorized to practice medicine, dentistry, podiatry or veterinary medicine, or
(b) Who is
(i) In a class of persons prescribed by the minister for the purpose of this definition.

This is further clarified under section 2 of the PODSA Pharmacy Operations General Regulation:
The following classes of persons are prescribed for the purposes of paragraph (b) (i) of the definition of “practitioner” in section 1 of the Act:
(a) Midwives;
(b) Nurses practicing nursing as nurse practitioners, registered nurses or registered psychiatric nurses;
(c) Optometrists;
(d) Pharmacists, but only for the purpose of prescribing the following drugs for emergency contraception:
(i) Ethinyl estradiol
(ii) Norgestrel;
(iii) Progestin;
(e) Naturopathic physicians

Since pharmacists are only considered practitioners under a very narrow and specific set of circumstances, out of an abundance of caution our recommendation is not to submit electronic claims to private payers under a pharmacist’s license at this time.

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