Examples of Policy Wording for Expanded Pharmacist Services

Insurance policy options to implement coverage of expanded pharmacist-provided services

Many private payers ask, “If I want to extend coverage for expanded pharmacist services, what is the best way to do that?”  Just like private plans themselves, there are multiple ways in which private payers could extend coverage.

A few of the policy options available to private insurers to extend coverage include the following: 

1. reimbursement as part of a drug plan by creating a list of PINs as what Pharmacare has done
2. reimbursement as part of the paramedical services under the Extended Health Care benefit with cap on the Extended Health Coverage annual maximum
3. reimbursement under a plan member’s Health Spending Account.

The following are examples of actual policy wording that is currently in use.  Note that the respective organizations are not identified for purposes of confidentiality.

Example 1

• Cognitive services fees could include an annual maximum payment of $25 for the initial medication assessment, in addition to the provincial government's payment (they would need to be first payer); $5 payment for each subsequent medication review in addition to each payment from the provincial government (for those key disease states currently identified by the provincial government).
• Cognitive service fees could also include payment for smoking cessation counselling, up to $150 per person for the first time, and an addition $150 per person could be paid on a prior approval basis  (hopefully people would quit, but they may need more than one session).
• Cognitive service fees could also include payment for adherence counselling to a maximum of $100 per person per year.
• Cognitive service fees could also include payment for medication counselling related to support when initially prescribed a new special authorization medication up to $25.
• Cognitive service fees could also include payment for ongoing medication counselling for extended disability claimants with multiple medications.

Example 2

Benefit Details

Non-dispensing services provided by a licensed pharmacist

Your Plan's Coverage

$500 per calendar year(s) for Pharmacist non-dispensing services, such as:

• medication management (e.g., medication reviews, annual care plans, narcotic and addiction consulting services)
• chronic disease prevention and management (e.g., diabetes, cardiovascular, respiratory, rheumatoid arthritis)
• self-care consultations (e.g., assessment, prescribing and monitoring for minor ailments)
• smoking cessation services

Expenses for some of these professional services may be payable in part by provincial plans. Coverage for the balance of such expenses prior to reaching the provincial plan maximum may be prohibited by provincial legislation. In those provinces, expenses under this benefit program are payable after the Provincial Plan's maximum for the benefit year has been paid.

Recommendation by a physician for Professional Services is not required.

Example 3

Eligible expenses under a Health Spending Account:

Non-dispensing services offered by a qualifying pharmacist.  This could include prescription related services, wellness services, medication reviews, treatment of minor ailments, and comprehensive medication management services.

Download Examples of Policy Wording