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| Insured Prescription Drug Plan Regulations |
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Health Services and Insurance Act
R.S.N.S. 1989, c. 197
O.I.C. 74-1043 (September 24, 1974), N.S. Reg. 88/74
as amended up to and including O.I.C. 90-963 (July 31, 1990), N.S. Reg. 221/90
Definitions
1 In the Act and in the regulations under this Part
(a) "Commission" means the Health Services and Insurance Commission;
(b) "dentist" means a dentist as registered under the Dental Act or is licensed as a dentist by the licensing authority of the jurisdiction in which he writes a prescription;
(c) "identification card" means that card issued to a resident under the insured prescription drug plan;
(d) "insured prescription drugs" means those drugs, appliances and services to which residents are entitled under the plan;
(e) "non-participating pharmacy" means a pharmacy which operates outside the insured prescription drug plan, including an out-of-province pharmacy which has not been designated by the Commission as a participating pharmacy;
(ea) "non-participating provider" means a non-participating pharmacy and a physician or institution which has not been designated under Section 4(c) of these regulations;
Clause 1(ea) added: O.I.C. 74-1179, N.S. Reg. 99/74.
(f) "participating pharmacy" means a pharmacy which operates within the insured prescription drug plan, including an out-of-province pharmacy which has been designated by the Commission as a participating pharmacy;
(g) "participating provider" means a participating pharmacy and a designated physician or institution under Section 4(c) of these regulations;
(h) "pharmacy" means a pharmacy as licensed under the Pharmacy Act or is licensed as a pharmacy by the licensing authority of the jurisdiction in which it operates;
(i) "pharmaceutical review committee" means the committee established by the Commission under these regulations and designated as the Pharmaceutical Review Committee;
(j) "pharmaceutical tariff" means all the various payment levels determined by the Commission after consultation with the Nova Scotia Pharmaceutical Society to represent fair and reasonable payment for insured services and includes an amount to be paid in respect to the cost of an insured prescription drug and the dispensing fee of the pharmacy for such insured prescription drug under the plan;
(k) "physician" means a physician as registered under the Medical Act or is licensed as a physician by the licensing authority of the jurisdiction in which he writes a prescription;
(l) "plan" means the insured prescription drug plan;
(m) "prescription" means a formula or direction given by a physician or dentist of a remedy for or as treatment for a disease or disorder, prescribing the ingredients with or without the method of using;
(n) "resident" means a resident as described in the regulations for the purposes of the hospital insurance and medical services insurance plans and who is sixty-five years of age or who is described under Section 4(2) of the Act.
Coverage
2 (1) All drugs required by law to be prescribed by a physician or dentist shall be insured benefits under the prescription drug plan, unless specifically excluded from time to time by the Commission.
(2) As determined from time to time by the Commission, such other drugs, biologicals and related preparations and appliances as prescribed by a physician or dentist shall be insured benefits under the plan.
Section 2 replaced: O.I.C. 86-759, N.S. Reg. 148/86.
Exclusions
3 Except as specifically approved by the Commission, the following categories of items will be exclusions under the program:
1. patent medicines and household remedies;
2. over-the-counter analgesics;
3. artificial sweetening agents;
4. over-the-counter mouth, throat, and nasal preparations;
5. over-the-counter vitamins;
6. dietary supplements and food products;
7. gauze, bandages, dressings and similar products;
8. soaps, cleansers and shampoos, medicated or otherwise;
9. supportive or physical aids or devices, mechanical or otherwise, prescription accessories, convalescent aids or other non-drug items of a similar nature;
10. cosmetic, health and beauty aids;
11. diagnostic agents or preparations;
12. laxatives, antacids, cough and cold remedies;
13. delivery charges;
14. all medications not normally prescribed;
15. any insured service to which the resident is entitled to benefit under D.V.A., W.C.B., or any legislation of Nova Scotia or any other jurisdiction.
Providers
4 Insured benefits under the plan may be obtained from any of the following providers of pharmacy services:
(a) a participating pharmacy;
(b) a non-participating pharmacy;
(c) a physician or an institution as provided for in these regulations;
(d) a supplier of ostomy equipment or diabetic supplies as approved by the Commission as a participating provider for the sole purpose of providing such supplies as insured services.
Clause 4(d) replaced: O.I.C. 75-857, N.S. Reg. 55/75.
5 (1) A physician may be designated as a provider of pharmacy services by the Commission where there is no pharmacy located within fifteen miles by public highway of the office of the physician or in such other circumstances as designated by the Commission after consultation with the Pharmacy Review Committee.
Subsection 5(1) amended: O.I.C. 78-460, N.S. Reg. 101/78.
(2) An institution, including a hospital, nursing home, home for the aged, extended care facility or penal institution may be designated as a provider of pharmacy services by the Commission after consultation with the Pharmacy Review Committee where
(a) there is no pharmacy located within fifteen miles by public highway of the institution or in such other circumstances as designated by the Commission after consultation with the Pharmacy Review Committee;
Clause 5(2)(a) amended: O.I.C. 78-460, N.S. Reg. 101/78.
(b) the pharmacy service is provided in compliance with the health and quality control standards as set from time to time by the Commission; and
(c) the pharmacy service is provided only to a resident then in or under the custody of the institution.
6 Subject to these regulations every pharmacy licensed under the Pharmacy Act at the inception of the plan shall be deemed to be a participating pharmacy unless such pharmacy elects to be a non-participating pharmacy.
7 (1) Where
(a) any participating provider of pharmacy services or any person claiming benefits under the plan has been convicted of an offence under this Act or the regulations and the conviction has become final by affirmation on appeal or by expiry without appeal of the time allowed for appeal; or
(b) the Commission is of the opinion, after due inquiry, that any participating provider of pharmacy services or any person claiming benefits under the plan has fraudulently or improperly submitted or assisted in the submission of a claim for payment under the plan;
(c) the Commission may order in the case of a pharmacy that it not be permitted to be a participating provider of pharmacy services and in the case of any person claiming benefits under the plan, that their participating in the plan be restricted during such period or periods as the Commission from time to time determines;
(d) the Commission or Commission staff may consult with the Pharmaceutical Society and the Pharmacy Association of Nova Scotia or either of them before or after the holding of a due inquiry, and may provide them with copies of material under review.
Subsection 7(1) replaced: O.I.C. 84-1131, N.S. Reg. 244/84.
(2) A provider of pharmacy services or any person with respect to whom an order is in force under subsection (1) may within thirty days of the making of the order appeal from it to the Minister of Health who may confirm, reverse or modify the order.
7A (1) Where the Commission is of the opinion that a person habitually claims under the plan for benefits that are unnecessary or otherwise unnecessarily utilizes benefits provided by the plan, the Commission may order
(a) that the person shall only be entitled to obtain insured prescription drugs from such provider of pharmacy services as the Commission may from time to time determine after considering the person's choice of a provider;
(b) that entitlement of or participation by the person under the plan otherwise be restricted in such manner and to such extent as the Commission may from time to time determine.
(2) Where the Commission orders pursuant to subsection (1) that entitlement of or participation by a person be restricted, a claim against the plan for payment of insured prescription drugs shall be paid by the Commission only if the claim is made by a provider determined by the order to be a provider from which the person is entitled to obtain insured prescription drugs.
Section 7A added: O.I.C. 82-611, N.S. Reg. 108/82.
8 A resident entitled to receive benefits under the plan shall when obtaining such benefits from a participating provider produce and show to such provider an identification card or otherwise show proof of eligibility for insured services satisfactory to the provider.
9 (1) Except as otherwise stated a participating provider shall not charge a resident entitled under the plan for insured prescription drugs above an amount established as a pharmaceutical tariff.
Subsection 9(1) amended: O.I.C. 74-1179, N.S. Reg. 99/74.
(2) Where a participating provider supplies in good faith an insured prescription drug on the presentation of an identification card which is subsequently determined by the Commission to be invalid, the Commission shall reimburse such participating provider to the extent permissible under the plan until such time as the participating provider has been notified that the identification card is invalid.
10 A claim made against the plan for payment for insured prescription drugs by a provider shall be made on such forms and in such manner as may be determined from time to time by the Commission.
11 Where a provider has a reasonable doubt as to the eligibility of the resident or as to whether the drug prescribed is insured under the plan, nothing shall prevent such provider from charging an eligible resident for an insured prescription drug to the limit of the pharmaceutical tariff in which case the resident may claim against the plan in the same manner as if the insured prescription drug was obtained from a non-participating pharmacy.
12 Except as otherwise determined by the Commission, a claim by a provider in respect of insured prescription drugs shall not be payable under the plan unless it contains the following information and is made on a form prescribed by the Commission for that purpose:
(a) M.S.I. Number;
(b) group number;
(c) name of resident;
(d) provider identification number;
(e) name of provider;
(f) name and identification number of prescribing physician or dentist;
(g) date on which prescription was filled;
(h) prescription number;
(i) indicating original or repeat prescription;
(j) drug name, strength and manufacturer, or Canadian Drug Identification Code Number;
(k) number of refills remaining;
(l) quantity prescribed;
(m) number of days supply of medication and directions for use;
(n) drug classification;
(o) total charge for prescription showing drug cost and dispensing fee;
(p) signature of resident or agent of resident;
(q) signature of pharmacist or an agent of the pharmacist authorized by the pharmacist, or a signature of the designated physician or of the designated institution's authorized agent.
Non-participating pharmacies
13 A non-participating pharmacy
(a) shall not be entitled to charge an insured resident unless prior to dispensing the insured prescription drug notice is given to the resident or such other person acting on behalf of the resident that the pharmacy does not participate in the plan and that the pharmacy intends to charge the resident for the insured prescription drug dispensed; and
(b) where the pharmacy has made a charge to the resident the pharmacy shall at the time the insured prescription drug is dispensed complete the claim form prescribed for that purpose or provide the resident or some other person acting on behalf of the resident with sufficient information to enable the resident to complete the form in a manner satisfactory to the Commission.
14 A resident who receives prescription drugs under the plan from a non-participating pharmacy shall be entitled to payment by the plan in an amount equal to that which would have been paid to a participating pharmacy for the same prescription drugs.
15 (1) By notifying the Commission at any time a participating provider may apply to become a non-participating provider or a non-participating provider become a participating provider.
Subsection 15(1) replaced: O.I.C. 74-1179, N.S. Reg. 99/74.
(2) A non-participating provider notifying the Commission under this Section shall become a participating provider on the first day of the month following the expiration of thirty days after the day on which the Commission receives the notification or at such earlier date as the Commission determines.
Subsection 15(2) replaced: O.I.C. 74-1179, N.S. Reg. 99/74.
(3) A participating provider notifying the Commission under this Section shall become a non-participating provider on the first day of the month following the expiration of sixty days after the day on which the Commission receives the notification.
Subsection 15(3) replaced: O.I.C. 74-1179, N.S. Reg. 99/74.
(4) Prior to the inception of the plan or at the opening of any new pharmacy, a pharmacy may elect to be a non-participating pharmacy. The pharmacy shall notify the Commission of such election within thirty days from the date of inception or from the date on which the pharmacy opened, and such election shall be effective from and on the day of inception or as the case may be the day on which the pharmacy opened. Subsection 15(4) replaced: O.I.C. 74-1179, N.S. Reg. 99/74.
(5) Notwithstanding the provisions of this Section, a participating provider may become a non-participating provider following the expiration of thirty days after the day on which such provider notifies the Commission of such intention where the Commission or the Governor in Council makes any change in the substance of the Insured Prescription Drug Plan and where the Nova Scotia Pharmaceutical Society has objected in writing to the Commission to such change.
Subsection 15(5) added: O.I.C. 74-1330, N.S. Reg. 56/75.
(6) Notwithstanding the provisions of this Section, a participating provider may become a non-participating provider following the expiration of ten days after the day on which such provider notifies the Commission of such intention where the Commission takes action pursuant to subsection (3) of Section 20 without the agreement of the Pharmacy Association of Nova Scotia.
Subsection 15(6) added: O.I.C. 83-633, N.S. Reg. 124/83.
16 Except for claims incurred while a participating pharmacy, the Commission shall not make payments under the plan directly to a non-participating pharmacy.
Claims - General
17 A claim against the plan for payment of insured prescription drugs shall be honoured by the Commission only if it is received by the Commission within six months of the date upon which such drugs were supplied unless in the opinion of the Commission there was good and sufficient reason for delay in submitting such claim.
Section 17 amended: O.I.C. 74-1330, N.S. Reg. 56/75.
18 No payment shall be made under the plan for drugs supplied on the basis of a prescription following the expiration of one year after the date of the first supplying of such drugs on the basis of the same prescription.
19 The Commission may designate a form of prescription order to be used by a physician or dentist upon which claims against the plan shall be based.
Amount of payment
20 (1) The Commission shall pay an amount for an insured prescription drug benefit equal to the cost of such drug as determined by the Commission and a fee, or in the case of an institution, a pharmaceutical consulting fee where such service is provided, as determined by the Commission.
(2) Payment made under this Section shall not include reimbursement for any charge not approved by the Commission, including the charge for delivering a drug or charges for any other ancillary service.
(3) In the event that the amount payable for an insured prescription drug benefit does not, in the opinion of the Commission, represent a fair value, or if such amount cannot be determined in accordance with the pharmaceutical tariff, the Commission shall fix a fair and reasonable amount payable for such benefit.
Payment to providers
21 The Commission shall pay for insured prescription drugs in the following manner:
(a) in the case of a participating pharmacy or designated physician or institution, directly to such provider of pharmaceutical services;
(b) in the case of a non-participating pharmacy, directly to the resident upon completion of forms prescribed by the Commission.
22 The Commission may make payment to the assignee of a participating pharmacy.
23 Except as otherwise determined by the Commission no participating provider shall have the right to payment by the Commission under the plan unless all conditions established under the Act and regulations have been fulfilled.
Section 23 amended: O.I.C. 74-1179, N.S. Reg. 99/74.
24 The Commission may make necessary adjustments in the cumulative amounts paid to providers so as to conform with the allowable costs of insured prescription drugs and fees.
25 The Commission may establish
(a) procedures for the filing of claims by providers and residents;
(b) in consultation with the Pharmacy Review Committee procedures for the auditing of claims by providers; and
(c) a Pharmacy Review Committee, a Pharmaceutical Tariff Committee, and such other committees as it deems advisable to make recommendations to the Commission on the operation of the plan.
26 Where a Pharmacy Review Committee is established it shall
(a) review the professional activities related to the delivery of pharmaceutical services under the plan and may make recommendations to the Commission regarding providers of pharmacy services and lists of drugs which may be insured from time to time under the plan; and
(b) report to the Commission and such other body as the Commission directs and the respective professional organizations at least semi-annually.
Section 27 repealed: O.I.C. 90-963, N.S. Reg. 221/90.
Section 28 repealed: O.I.C. 78-971, N.S. Reg. 174/78.
29 Providers of pharmaceutical services shall supply information as the Commission determines is necessary to audit the claims of the providers under the plan.
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