Filling ODB Palliative Care Claims

To allow patients timely access to medications commonly required during end-of-life care, a list of drugs has been compiled into a Facilitated Access Palliative Care Medications List as part of the Ontario Drug Benefit Formulary. Effective March 23, 2007, drugs listed in Part VI of the Formulary can be accessed by authorized physicians; a list of authorized physicians will be available to pharmacies on March 12, 2007.

The Facilitated Access Palliative Care Medications will not require Individual Clinical Review (ICR) forms for coverage for the initial six-month course of therapy. Coverage beyond the initial six-month period and requests for drugs that are not on the list will need to be submitted to the ICR Unit as usual.

Palliative Care medication claims to be reimbursed by ODB must be prescribed in accordance with the following patient eligibility criteria:

  • 'This patient has a terminal illness and has chosen outpatient palliative treatment. Life expectancy is less than six months and the medications are being requested for symptom control for a maximum period of six months.
  • To facilitate the reimbursement process at the pharmacy, the prescriber is asked to indicate either, 'Palliative' or 'P.C.F.A.', on the prescription to signify that the patient meets the above-noted eligibility criteria. This would be an indication to the pharmacist that these medications may be reimbursed under this mechanism.

(As indicated in BBS No. 7012 posted March 5, 2007 Re: Formulary Edition No. 39, Update 15)

General questions about the Palliative Care program and issues with claim adjudication should be directed to the ODB Help Desk at 1-800-668-6641.

To submit an ODB claim for a Palliative Care medication

Palliative Care claims must be adjudicated with the pseudoDIN assigned to the drug, as per the Facilitated Access Palliative Care Medications List in the Formulary. Claims will be rejected if they are submitted with the drug’s real DIN.

  1. Open the new or refill prescription in Rx Detail as usual, using the drug’s real DIN.
  2. Enter or review the basic prescription information (QA, Qty, DS, SIG, etc...).
    • If the drug is not eligible for ODB or is a Limited Use product, follow the instructions below. Otherwise skip to step #4.
    • If the drug is not eligible for ODB: Press the Extended tab. Select the Eligibility Override checkbox. The prescription’s billing code and price re-evaluates to reflect DB as the primary third party.
  3. If the drug is flagged as Limited Use: Press the Extended tab. Select the Section 8 checkbox (this allows the prescription to be filled without an MR Code).
  4. Press the Third Party tab. Ensure Claim 1 is displayed - if not, press the Previous button to return to Claim 1.
  5. Enter the drug’s Palliative Care pseudoDIN in the Alternative DIN field.
  6. Continue to fill the prescription as usual.