Pharmacy (Chemist Medications) policy

Policy

The TAC can fund medications for the treatment of an injury or condition directly resulting from a transport accident which is prescribed by a medical practitioner or dentist.

This policy must be read in conjunction with the following:

Dose Administration Aids policy

Ketorolac policy

Medication to Treat Erectile Dysfunction policy

Non-Established, New or Emerging Treatments and Services policy

Opiod policy

Sedatives (including Hypnotics and Anti-anxiety Medications) policy

Special Food and Special Food Formula policy

Topical Non-Steriodal Anti-Inflamatory Drugs (Gels, Creams and Sprays) policy

Treatment of Transport Accident Injuries with Drugs of Dependence policy

Vaccinations policy

Vitamins, Minerals and Complementary Medications policy

Weight Loss Treatment and Services policy

Guidelines

What medications can the TAC fund?

The TAC can fund the reasonable cost of medications which are:

• required as a result of a transport accident injury
• requested or prescribed by a registered medical practitioner or registered dentist and provided by a registered pharmacist
• provided in accordance with the Pharmaceutical Benefits Scheme (PBS), where clinically appropriate and available, and
• registered (not listed) in the Australian Register of Therapeutic Goods (ARTG).

What is the Australian Register for Therapeutic Goods (ARTG)?

The Australian Register for Therapeutic Goods (ARTG) is a list. 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.

Are TAC clients entitled to Pharmaceutical Benefits Scheme (PBS) medications?

TAC clients are entitled to medications under the Pharmaceutical Benefits Scheme (PBS). The TAC expects that clients will present their Medicare card, and Healthcare card if applicable, to the dispensing pharmacist.

See also the PBS information on the Medicare Australia website.

The TAC considers that where a client is entitled to use the PBS, the reasonable cost of medications is the charge set out in the PBS.

The TAC can fund all the normal patient contribution charges set out in the PBS including brand or therapeutic premiums.

Non-Australian residents, including overseas visitors who are receiving TAC funded medical services within Australia (with the exception of visitors from countries with Reciprocal Health Care Agreements with Australia such as the United Kingdom, New Zealand, Netherlands, Sweden, Finland, Italy, Malta, and the Republic of Ireland), are not entitled to use the PBS. The TAC will be liable for the full reasonable retail cost of prescription drugs in such instances.

Can the TAC fund Vitamins, Minerals and Complementary Medications?

Refer to the Vitamins, Minerals and Complementary Medications policy.

Can the TAC fund medications for a condition that is indirectly related to the transport accident?

The TAC will not fund medications for a condition that did not arise as a result of injuries sustained in a transport accident. If the condition existed prior to the transport accident, a full explanation, basis of apportionment or duration of liability should be provided by appropriate medical practitioner. The TAC can fund the treatment of a condition where the transport accident was a substantial contributor or cause.

Can the TAC fund off-label use of a medication?

Where a treating medical practitioner prescribes a medication "off-label", ie. the intended use differs from that prescribed on the product information sheet or label (the use differs in the form of dose, age, indication or route), the TAC requires the treating medical practitioner to provide written clinical justification for the off-label use. Refer to the Non-Established, New or Emerging Treatments and Services policy.

What information does a client need to submit to claim pharmacy expenses?

A client's claim for pharmacy medications must be submitted within the following guidelines:

• A claim for pharmacy expenses must be submitted on a Pharmacy Declaration form. Original receipts must be itemised and supplied with the Pharmacy Declaration form
• Receipts must be from a registered pharmacy
• Expenses must be claimed within 2 years from the date of purchase.

The itemised tax receipt must include the following information:

• Pharmacy name and address
• Client's name, address and/or claim number (this can be handwritten, and is not required when the Pharmacy Declaration form is submitted)
• 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 PBS code) private or over-the-counter (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 client ask their pharmacist for a dispensary computer-generated tax receipt for dispensed medications/iems which contains the aboe information, so that reimbursement can be processed correctly and efficiently.

Please note that a register receipt may not contain all this information.

The TAC will reimburse pharmacy expenses in line with the fee structure in the Requirements for Invoicing the TAC and Worksafe Victoria information sheet. If a pharmacy charges above these rates the TAC client will be responsible for paying any excess charges.

See also the Client Pharmacy Expenses information sheet and Pharmacy Declaration form.

What are the TAC's invoice requirements for direct billing accounts?

Invoice Requirements
The TAC require the following information in order to process your invoice:

Before submitting an account

Before a pharmacy submits an account to the TAC:

• Ensure the client has an accepted TAC claim (and has met the medical excess). Remember that only one client may appear on each account

The pharmacist should not issue the TAC with receipts or client history reports.

Accounts should be in the form of a dispensary computer-generated tax invoice and must be addressed to the TAC.  The status of an item for example, over-the-counter (OTC), may be handwritten onto the tax invoice.

Refer to the Pharmacist Billing information sheet for more information.

Are TAC clients entitled to claim Private script (non-PBS) medications?

All TAC clients with a Medicare card are entitled to medications prescribed under the PBS. Medications should be prescribed under the PBS when clinically appropriate and available.

The TAC can pay for non-PBS (privately prescribed) medications if the TAC is satisfied that the medications are clinically appropriate for the accident-related injury or illness and there is no readily available alternative to the PBS.

For non-PBS private prescription items the TAC can pay in line with the following fee schedule:

Wholesale price	Mark up 1	Dispensing fee
Less than $100	Up to 60%	$7.50
Between $100 and $400	Up to 25%	$7.50
Greater than $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 $11.70.  For more information refer to the Schedule 8 drug restrictions in this policy and Treatment of Transport Accident Injuries with Drugs of Dependence policy, which states that funding for these medications outside the PBS will be considered in exceptional circumstances only.

Are there restrictions on the quantities and dosage dispensed for the TAC funded medications?

• Maximum Therapeutic Dose - The TAC will usually only fund medications up to the maximum therapeutic dose as determined by the manufacturer. (This dose is considered to be the quantity and the frequency recommended in the consumer product information). The TAC can fund over the recommended dose if:
  • this is under the written instruction of the prescribing medical practitioner or dentist,
  • the request is clinically justified.

This applies to both over-the-counter and prescription medication. Note that where a medical practitioner prescribes a dosage over the limit for prescription medicines, on the PBS, he/she must obtain an authority from Medicare Australia. Under these circumstances a private script will not be funded.

• Restrictions on quantities dispensed - Pharmacists must supply medications, particularly drugs where addiction and tolerance are a risk, according to the medical practitioner's instructions. If the patient requires an increase in quantity outside the medical practitioner's request the patient should be referred back to the medical practitioner. The TAC will not automatically fund quantities of medications beyond the medical practitioner's or dentist's request except in exceptional circumstances, such as overseas travel. If a registered medical practitioner believes exceptional circumstances apply, the TAC can consider funding if:
  • the medical practitioner provides written clinical rationale to the TAC for consideration and approval, prior to prescribing such medications.
  • the maximum quantity of medications to be paid for does not exceed 12 weeks.
  • the prescription is endorsed by the prescribing medical practitioner in accordance with Regulation 24 of the PBS Guidelines, for dispensing repeat quantities.

This policy does not apply to Schedule 8 medications. Schedule 8 medications will not be paid to cover overseas travel or bulk supply.

• Schedule 8 drug restrictions - Due to the inherent risks associated with these drugs for abuse and the governmental systems in place to monitor their use, the TAC can only fund Schedule 8 drugs when they are prescribed through the PBS system. If a medical practitioner believes PBS medications are not suitable and an exemption under this policy is required, he/she must provide written clinical rationale to the TAC Clinical Panel to consider and approve, prior to prescribing such medication. If an exemption is not granted payment of private scripts for Schedule 8 medications will be denied. Refer to the Treatment of Transport Accident Injuries with Drugs of Dependence policy.

Can the TAC fund over-the-counter (OTC) pharmacy items?

Over-the-counter (OTC) items include medications and pharmacy items which can be sold by a pharmacist without a prescription, e.g. analgesics and laxatives, dressings, bandages, supports and syringes.

The TAC can pay the reasonable costs of OTC medications required as a result of transport accident injury which 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.

The TAC can pay the reasonable costs of non-drug pharmacy OTC items (e.g. wound dressing products, bandages, dressings) required as the result of transport accident injury which are:

• supplied by a registered pharmacist, and
• requested by a registered medical practitioner or dentist.

The TAC pricing policy regarding the reasonable costs of OTC items is in accordance with the following:

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 medical practitioner prescribes an OTC item listed on the PBS, the pharmacist is entitled to dispense the item through the PBS and invoice the TAC for the patient contribution.  The TAC may request Pharmacists to produce documentation (the request from a medical practitioner or registered dentist) supporting the invoicing of OTC items to treat TAC clients.

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 accident-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.

Can the TAC fund Herbal remedies?

The TAC will not pay for herbal remedies as they are not registered on the ARTG. For exceptions to this policy, refer to the Vitamins, Minerals and Complementary Medications policy.

Can the TAC fund scar concealing products/make-up?

The TAC can fund special scar concealing products/make-up used to disguise scarring as a result of a transport accident injury.

Can the TAC fund sunscreen?

The TAC cannot fund suncreen as this is considered to be a general purpose item used for protection against the sun and skin cancer.

Can the TAC fund Medications provided to hospital patients?

Public Hospitals

The TAC will not pay for medications provided to public hospital in-patients, as the in-patient (casemix) fee payable to the hospital covers these costs. However, the TAC will consider funding for accident-related prescribed medications supplied to public hospital in-patients on the day of discharge/separation.

The TAC can fund for accident-related prescribed medications provided to public hospital outpatients.

Funding will be made in accordance with the PBS rates, including concession and safety net entitlements, or if a private prescription is required at reasonable community standard rates.

Private Hospitals

Refer to the Hospitals - Private policy.

Referral by the TAC to regulatory bodies and suspension of payment

If the TAC has any concerns about the adequacy, appropriateness or frequency of a service or the conduct and competency of a service provider (such as prescribing pharmacy items without obtaining the appropriate permit), the TAC may refer the matter to the appropriate regulatory body for investigation. The TAC may also suspend payment of any services by a provider until the regulatory body has notified the TAC of its intentions. In addition, the TAC can, in some circumstances, disclose information to the regulatory body. Refer to section 131A of the Transport Accident Act 1986.

In relation to Pharmacy (Chemist Medications) what will the TAC not fund?

The TAC will not fund:

• treatment or services for a person other than the injured client
• vitamins or minerals that have been listed (as opposed to registered) on the ARTG except for those listed within the Vitamins, Minerals and Complementary Medications policy
• treatment or services where there is no clinical justification
• treatment, services or equipment where there is no published evidence in a recent peer-reviewed journal article that the treatment, service or equipment is safe and effective. Refer to the Non-Established, New or Emerging Treatments and Services policy
• the cost of telephone calls and telephone consultations between providers and clients, and between other providers, including hospitals
• Schedule 4 and Schedule 8 drugs that have not been prescribed and used in the manner required by the Drugs and Poisons Regulation Group (DPRG) in Victoria or the corresponding body in another State or Territory in Australia
• treatment or services provided outside the Commonwealth of Australia
• treatment or services provided more than 2 years prior to the request for funding except where the request for payment is made within 3 years of the transport accident. Refer to the Time Limit for the Application for Payment of Medical and Like Expenses policy.

Can the TAC fund medications dispensed by a member of a client's immediate family?

Refer to the Funding Treatment by a Member of a Client's Immediate Family policy.