Revised Arrangements for the Efficient Funding of Chemotherapy - Key issues for public hospitals - prescribers and pharmacists
Factsheet: Full implementation from 1 April 2012 - Key issues for public hospitals
Page last updated: 9 November 2012
1. What is changing from 1 April 2012?
a. From 1 April 2012 public hospitals will need to prescribe and dispense PBS chemotherapy drugs in accordance with the Efficient Funding of Chemotherapy (EFC) Special Arrangement.
b. This means that prescribers in public hospitals will need to:
i. prescribe PBS chemotherapy drugs in milligrams (or other appropriate unit of measurement).
ii. seek authorities for increased maximum amounts or increased repeats through the Department of Human Services (DHS) by calling 1800 888 333. The Authority Notification System (ANS) used by pharmacy to obtain authorities for chemotherapy drugs will cease before 1 April 2012.
iii. seek authorities for Complex Authority Required (CAR) drugs as per current practice. Authority approvals for CAR drugs must be in writing or where allowed in the EFC Schedule can be obtained by phoning 1800 700 270.
c. This means that pharmacists will:
i. use item codes from the Schedule of Pharmaceutical Benefits for Efficient Funding of Chemotherapy – Section 100 Arrangements Supplement (the Schedule for EFC), and not use item codes from the Chemotherapy Pharmaceuticals Access Program (CPAP), which ceases before 1 April 2012.
ii. use item codes for trastuzumab (Herceptin®) and bortezomib (Velcade®) from the Schedule for EFC, and not from the Special Arrangement nor general schedule (respectively), as these arrangements cease before 1 April 2012.
iii. dispense any combination of vials to make up the script, or have it prepared by a third party, but will only be paid for the most cost-efficient combination.
d. Pharmacists in public hospitals will not be able to use ANS, which ceases before 1 April 2012.
e. Pharmacists in public hospitals will be able to claim repeats without a paper script – ie paperless
f. Public hospitals will be eligible for a $40.64 preparation fee per injection/infusion to recognise the specialist nature of preparing chemotherapy medicines.
g. For patients, this means that there are no co-payments for PBS chemotherapy repeat prescriptions, only one co-payment on each original prescription. For public hospitals which would usually cover the patient co-payment, this means that the applicable patient co-payment will not be subtracted from the reimbursement on repeats.
2. How do I supply a drug if it was prescribed prior to 1 April 2012 with an old (non- EFC) PBS code?
a. Any outstanding chemotherapy scripts that were prescribed prior to 1 December 2011 are no longer valid for supply. These scripts will need to be replaced and rewritten (if applicable), and the patient will be charged another co-payment on the original of this new prescription.
b. Any outstanding chemotherapy scripts that were prescribed using a medication chart, prior to 1 April 2012, should be converted into the EFC claiming format (subject to all necessary information being provided in the medication chart).
3. How do I supply trastuzumab or bortezomib if it was prescribed prior to 1 April 2012 with an old (non-EFC) PBS code?
a. DHS has put in place special arrangements for trastuzumab and bortezomib, whereby the authorities granted prior to 1 April 2012 are in accordance with the EFC PBS codes (even if the original prescription is otherwise). This means that claims will be accepted under the Revised Arrangements.
4. How do I prescribe/dispense drugs with streamlined authority codes?
a. Prescribers must continue to enter the streamlined authority code on the prescription as per usual. Prescribers should make sure that they are using the correct code from the current version of the Schedule (both general and EFC).
b. Pharmacists must enter the streamlined authority code into the claim.
c. Streamlined authority codes may be applicable to general schedule drugs, not just chemotherapy drugs under the EFC
5. I am a prescriber - when do I need to obtain an authority?
a. Prescribers, not pharmacists, are required to seek authorities. The National Health Act 1953 requires that the prescriber be the decision maker for their patient’s medicine requirements.
b. Chemotherapy drugs to be supplied in public hospitals either:
i. Don’t require an authority at all; or
ii. Require a streamlined authority code; or iii. Have a Complex Authority Requirement.
c. Chemotherapy drugs to be supplied in private hospitals either:
i. Don’t require an authority at all; or
ii. Require a streamlined authority code; or
iii. Have a Complex Authority Requirement; or
iv. Require an authority approval number to prescribe.
d. Paper scripts are required for all prescriptions that require a:
i. Authority approval number; or
ii. Authority approval number where an increased amount or increased repeat is required (except where the prescriber has recommended an increased amount on a repeat, by up to 10 percent of the original amount prescribed); or
iii. Complex Authority Requirement.
6. I am a prescriber - how do I obtain an authority (including a Complex Authority)?
a. Prescribers, not pharmacists, must obtain authority approval where applicable. Authorities are obtained through DHS, by calling 1800 888 333. Authorities require the use of paper scripts, and cannot be claimed as paperless.
b. DHS will provide all authority required approvals using private setting item codes. This will allow portability of scripts and ease of access to medicines by patients.
c. Public hospitals need to submit claims using public hospital item codes and the relevant authority prescription number. DHS will manage the item code mismatch at claims processing to facilitate payment.
7. What are the paperless claim provisions?
a. The Authority Notification System ceased on 1 April 2012. However, public hospitals are able to continue to dispense and claim from medication charts.
b. This means that approved public hospitals are able to lodge paperless claims for original and repeat prescriptions for all items listed in the EFC Schedule with the following exceptions:
i. Where the drug is Complex Authority Required; or
ii. Where an authority is required for an increased amount or increased repeats.
8. I am a pharmacist – how do I endorse a script or medication chart if I am directed to vary the dose of chemotherapy drug in an infusion??
a. You need to record:
i. the name of the authorised prescriber who gave the direction; and
ii. the means by which the pharmacist was notified of the direction (eg by phone or by fax); and
iii. the date and time the pharmacist was notified.
iv the dose the EFC prescription was varied to
v the name of the pharmacist making the endorsement
vi the signature of the pharmacist making the endorsement
9. Can a public hospital prescription be dispensed by a community pharmacy?
a. Yes. A public hospital prescription may be dispensed by a community pharmacy. To do so it must be:
i. Prepared on paper (ie not paperless, or medication chart);
ii. Prepared using a private hospital / private clinic item code; and
iii. Have any appropriate authority obtained by the prescriber.
10. Can a private hospital prescription be dispensed by a public hospital?
a. No. Prescriptions written outside of a public hospital can not be dispensed and claimed by a Section 94 approved public hospital authority (under the National Health Act 1953).
11. What happens if the prescribed drug has a national shortage?
a. Stock shortages can be isolated or widespread and can be for a few days or months. The Department will respond to stock shortages on a case by case basis.
b. Pharmacists should dispense the product that best fits the prescription despite there being a shortage.
c. In early 2012 the Government was advised of a potential national shortage of pegylated liposomal doxorubicin. From 1 April 2012, a new brand of doxorubicin was listed on the PBS through the EFC. The new brand is in full supply and available to be dispensed where other brands face shortages. Please see the latest EFC Schedule for further details of brands, forms and indications.
12. How are related pharmaceutical benefits prescribed/claimed (ie both general schedule and EFC Schedule)?
a. Related pharmaceutical benefits (eg antinauseants, antiemetics and some other chemotherapy drugs such as interferon) are available through the EFC Schedule, or the general Schedule of pharmaceutical benefits. These are differentiated by item code.
b. Related pharmaceutical benefits are not subject to the EFC preparation fee, nor the calculation of reimbursement based on the most cost-efficient vial combination.
13. Can related pharmaceutical benefits be claimed as paperless (originals and repeats)?
a. Yes. Related pharmaceutical benefits (eg antinauseants, antiemetics and some other chemotherapy drugs such as interferon) can be claimed as paperless in the public hospital setting where supplied through the EFC Schedule. Any supply using the PBS general Schedule of pharmaceutical benefits will require a paper prescription.
