Supportdoc Pharmacy Manual
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Page Count: 63
Pharmacy Manual
The information contained in this Pharmacy Manual does not
apply to pharmacy providers from the province of Quebec.
Pharmacy Manual 2
Table of Contents
Section 1 - General Information
About TELUS Health 6
Communicating With Cardholders: The Insurer’s Prerogative 7
Section 2 - The Telus Assure Claims Card
Sample Assure Claims Card 9
The Cardholder Identification Number 9
Carrier Number 10
The Cardholder Name Line 10
The Second Name Line 10
Other Text 10
Relationship Code and Date of Birth 11
Section 3 - TELUS Health Assure Claims Pharmacy Support Centre
Contact Information and Hours of Operation 13
Holiday Schedule 13
Section 4 - General Policies and Procedures
Procedures 15
Validation of Electronic Claims 15
Paper Claims 15
Incorrect Date of Birth 15
Claim Void 16
Claim Retransmission Requests 16
Balancing transactions 16
Pharmacy Payment Options 17
Pricing 17
Determination of Prescription Pricing 17
Keeping a Level Playing Field 18
What Can Be Charged to Cardholders 18
Deferred Payment Plans 19
Government Programs
WorkSafe BC (WSBC) 19
Ontario Workplace Safety and Insurance Board (WSIB) 19
Pharmacy Manual 3
Section 4 - General Policies and Procedures (continued)
Documentation Requirements 19
Authorization for Prescriptions 19
Verbal Refill Authorizations and Verbal Prescriptions 20
Pharmacist Prescribing/Adaptation 20
Continued Care Prescription (CCP)/Prescription Adaptation by a Pharmacist 20
Changing an Authorized Prescription 20
Dispensing Reduced Quantities 21
Documentation Retention 21
No Substitution 21
Pharmacist’s Signature/Initials Required 21
Prescription Not Dated 21
Policies 21
Classes of Drugs That May Have Restrictions 21
Days Supply/Early Refill 22
Dispensing the Same Drug More Than Once In a Five (5) Day Period 22
Vacation Supply 22
Compliance Packaging 22
Replacement Supplies (Lost/Stolen/Spoiled Prescriptions) 23
Procedure for Submitting Claims for Diabetic Supplies (Excluding Diabetic Devices) 23
Reimbursement Handling for Free and Discounted Meters and Training Fees 23
Allergy Products 23
Monthly Maximums 24
Submission & Eligibility Guidelines for Compounds 25
Submission Rules 25
Duplicating a Comercially Available Product 25
Unlisted Compound Codes 25
Ineligible Compounds 25
Ineligible Bases 26
Ineligible Ingredients 26
Ineligible Forms/Formats 26
Eligible Compounds 26
Reimbursement Time Guidelines for Compounds 27
Additional Notes 28
Provincial Compound Fee Guidelines 29
Section 5 - Drug Utilization Review (DUR)
Drug Utilization Review (DUR) 31
DUR Overview 31
DUR- How It Works 31
DUR Checks 31
Drug Interactions 32
What To Do When The DUR Rejects a Prescription? 32
Section 6 - Audits and The Audit Department
Overview: On-Site Pharmacy Audits 35
Fraud Tips 35
Pharmacy Manual 4
Section 7 - Co-Ordination Of Benefits
Provincial Co-Ordination Of Benefits (COB) 37
Private Co-Ordination Of Benefits (COB) 37
Limited Use Drugs For Ontario Seniors With Private Drug Plan Coverage 37
Spouses – 65 Or Over (Alberta) 37
Manitoba And Saskatchewan: Provincial Registration Management Program 38
Specialty Drug Program (SDP) 38
Section 8 - Drug Plan Types
Coverage 40
Natural health products and TELUS Health drug plans 41
Generic Plans 41
Frozen Formularies 41
The TELUS Health Assure Claims National Formulary 41
Exclusions 42
Dispensing Limitations 42
Maximum Allowable Cost Pricing (MAC) Or Reference Based Pricing (RBP) 43
The TELUS Health Maximum Allowable Cost (MAC) Program 43
New Drug Plan Coverage Based on Drug Price 45
Section 9 - The Trial, Maintenance And Prior Authorization Programs
Trial Drug Program 47
Procedure For Trial Program 47
Examples Of Drug Classes Included In TELUS Health’ Trial Program 47
Maintenance Program 48
Procedure For Maintenance Program 48
Trial And Maintenance Programs Combined 48
Procedure for Combined Trial and Maintenance Programs 48
Prior Authorization Program 49
Procedure For Prior Authorization Program 49
Section 10 - E-Sampling Program
E-Sampling Program 51
Section 11 - PSHCP
PSHCP 53
Appendicies
Appendix 1 Request For Change In Provider Profile 54
Appendix 2 Diabetic Pseudodin List 56
Appendix 3 Glossary Of Terms 57
Appendix 4 Common Reasons For Rejection 59
Appendix 5 Pins For Common Compounds 60
Index 61
Pharmacy Manual 5
Section 1
General Information
Pharmacy Manual 6
Section 1
General Information
TELUS Health
1000 rue de Sérigny, Longueuil (Québec) J4K 5B1
www.telushealth.com
TELUS Health Assure Claims Pharmacy Support Centre: 1 800 668-1608
About TELUS Health
TELUS Health is a leader in telehealth, electronic health records, remote patient monitoring, mobile home and community care,
consumer health, benefits management and pharmacy management. Our solutions give health authorities, providers, primary
care physicians, patients and consumers the power to enhance decision making and improve outcomes for Canadians. TELUS
Health is transforming how information is used across the continuum of care from hospital to home with solutions that foster
collaboration, drive prevention and empower care teams and patients. TELUS Health is Canada’s leading Healthcare IT Company
as cited by the Branham Group for the last three years and for being honoured as the ITAC Health Company of the Year (2008)
and Health Transformation Company of the Year (2009). For more information about TELUS Health, please visit
www.telushealth.com and www.telushealthspace.com
Assure Health Inc. was established in September of 1988. In November of 1999, Emergis Inc. (“Emergis”) acquired Assure Health.
In January 2008, TELUS demonstrated its strategic commitment to healthcare with the acquisition of Emergis and now operates
as a facility for the electronic submission of “pay-direct” health claims including prescription drug claims from point-of-service to
the adjudicator/payer.
As a part of our network, your pharmacy realizes benefits in processing, as follows:
Determination of product eligibility for most claims
Balancing of transactions
Instant confirmation of coverage of cardholders and their dependents
Automated payment of each transaction to a bank account of your choice (Electronic Funds Transfer, “EFT”)
Toll-free access to our Pharmacy Support Centre where your questions can be answered and your problems can be resolved
TELUS Health processes claims from pharmacies only by Electronic Data Interchange (EDI). It is our policy that we do not accept
paper claims submitted by a pharmacy for reimbursement. EDI processing provides the capability to handle more options to plan
designs and formularies, as the system’s “online” facility makes communication of every variation instantaneous. Where provincial
plans offer drug benefits to residents, TELUS Health can co-ordinate the public and private sector obligations, determining the
primary payment responsibility, i.e. whether we (on behalf of our insurance carriers) are responsible for the claim, and return that
information to you while the cardholder is still at the dispensary. We also provide co-ordination of claims payment between most
private payers. All claims are adjudicated based on the various co-pay and deductible amounts selected by the insurance carriers
and their policyholders. This manual identifies the policies that are to be followed for adjudication of claims for TELUS Health
Assure Claims Card cardholders. From time to time, policy changes will be communicated to you through faxed/ mailed/
or electronic updates. These communications will be considered part of, or modification to, the policies and procedures as set out
in this manual.
Pharmacy Manual 7
Communicating With Cardholders: The Insurer’s Prerogative
TELUS Health sincerely appreciates the role that the pharmacy staff plays in facilitating the smooth operation of pay direct drug
plans. Thank you for helping the cardholder take advantage of the most efficient means of processing their insurance claims.
The most frequent reasons for problems occurring at the point of service are that the cardholder information provided to us by
the insurance carriers does not match that transmitted by the pharmacy or the prescribed drug is not covered by the plan. The
insurance carrier is the only party capable of addressing these situations in that they maintain all cardholder eligibility records and
determine all parameters for claims payment.
The insurance carriers are very protective of their relationships with the plan sponsors and the cardholders. Therefore, they
have asked that TELUS Health have no direct contact with the plan sponsors and/or the cardholders. The only exception is
for audit purposes or to communicate the result of a request for Prior Authorization. Please do not give out the TELUS Health
Assure Claims Pharmacy Support Centre phone number to the cardholder. This number is for the exclusive use of our pharmacy
providers.
When the problem cannot be resolved by calling the TELUS Health Assure Claims Pharmacy Support Centre, advise the
cardholder to contact their Benefits Department through the cardholder’s employer. If the issue has resulted in non-payment of the
claim, your best course of action is to collect cash from the cardholder. When the problem is resolved, the cardholder can submit
your receipt to the insurance carrier for reimbursement.
Pharmacy Manual 8
Section 2
The TELUS Assure Claims Card™
Pharmacy Manual 9
Section 2
The TELUS Assure Claims Card
The TELUS Assure Claims Card will vary with respect to artwork and design depending on the insurance carrier and/or the
policyholder. The common characteristics of TELUS Assure Claims Cards include the following:
The Assure logo is most often present in the bottom right hand corner of the card.
The cardholder’s unique 20-digit ID number is shown in the middle side of the card.
There will always be a name that appears on the line directly beneath the 20-digit ID number. This could be the name of
the employee, the spouse or a dependent child. It is important to determine whether the person named on the card is the
employee, or a dependent, in order to select the correct relationship code when submitting claims.
In addition to the traditional plastic cards, some groups are opting to use paper cards for their employees. These cards may
be available for employees to print from a secure website.
Sample TELUS Assure Claims Card
The Cardholder Identification Number
Each cardholder is issued a unique 20-digit ID number that appears on their TELUS Assure Claims Cards and contains the
following information:
The first two digits identifies the cardholder’s insurance carrier, also referred to as the carrier number
The next six digits identifies the group or policy number
The next ten digits identifies the certificate number
The last two digits identifies the issue number
It is very important that claims be processed using the correct numbers to ensure that there are no unnecessary rejects for the
cardholder when new cards are issued.
ABC Company Limited
Carrier Group Certificate Issue
12 345678 0123456789 01
Employee Name
Pharmacy Manual 10
Carrier Number
The following insurance carriers and payers currently use TELUS Health to adjudicate drug claims for their clients. In the following
chart, the preceding numbers represent the insurance carriers’ or payers’ identification number, also commonly referred to as the
carrier identification or the carrier number.
11 Great-West Life 37 WSBC-BC
12 PSHCP 40 Global
16 Sun Life Financial 44 Johnston Group
20 Standard Life 49 WSIB
22 Chamber of Commerce 57 PBAS
29 Equitable Life 62 La Capitale
32 DA Townley 80 eSampling
35 Gingras
The Cardholder Name Line
There are many options available when printing the name on the TELUS Assure Claims Card. Some plan sponsors choose to print
the name of the primary cardholder on all cards issued for the family. Some will have cards issued with the name of the primary
cardholder on one and the spouse’s name on the other. Some cards for dependent students may be issued in the name of the
student, if attending school away from home. For this reason, it is important to determine the relationship prior to submitting the
claim to TELUS Health for adjudication.
The Second Name Line
There is an optional field used to enter customized messages. Types of information that could appear on this line are:
The primary cardholder’s company name
The spouse’s/dependent’s name if the surname is different to that of the primary cardholder
The abbreviation “O/A” which indicates an overage dependent covered through the primary cardholder
Plan design messages i.e. “DED EQUALS DISP FEE” or “EDI PROCESSING ONLY”
“DIFFÉRÉ/DEFERRED” on electronic reimbursement cards
Other Text
Other forms of text or messages that could appear on the front of the TELUS Assure Claims Card are as follows:
Dependent – this indicates the age at which benefits cease for dependent children (i.e. 18, 19, 21 or 25) for those cardholders
with family coverage. On the day that the dependent reaches the maximum age, coverage will automatically be terminated.
If the dependent is in full-time attendance at an accredited school, college, or university, they must register annually with their
insurance carrier/plan sponsor. Their coverage would be continued until they reach the maximum age as determined for overage
dependents. Some overage dependents will have their own card with “OA” and/or an expiry date. A disabled dependent may have
“DD” shown on their card.
Deductible – this varies among plan sponsors and refers to an amount of money that represents the cardholder’s out of pocket
portion. Their deductible could be indicated as a dollar/cents amount (“$.35”, “$2.00” etc.), as a percentage of the total cost of the
claim (“10%”, “20%”, “10% MAX TO $5.00”), or equal to the professional fee (“FEE”). A plan sponsor can choose to combine both
a deductible and a co-insurance. Some plans incorporate one or more levels of coverage where the deductible and/or
co-insurance vary depending on the DIN dispensed. You will be advised of the exact amount covered by the insurance carrier at
the time of processing.
Pharmacy Manual 11
Maximum Professional Fee (Fee Caps) – a plan sponsor may set a limit (dollar or percentage) on the amount of professional
fee that will be paid out by the plan. Any amount above the set limit up to the usual and customary fee becomes the responsibility
of the cardholder and is charged to them at the discretion of the pharmacy.
Due to the increasing complexity of plan designs, some plan sponsors will elect to keep some fields on the card blank
(i.e. deductibles, maximums and plan types). Other cards, for example, those issued to college or university students, may require
secondary identification such as a student ID number. In this case, the cardholder number is not shown on the front of the card.
Relationship Code and Date of Birth
Just as input of the correct date of birth in the approved format is critical to the EDI adjudication process, so is the correct
relationship code (Rel. Code) of the cardholder/dependent for whom drugs are being dispensed. Use of the proper Rel. Code is
important as it allows TELUS Health to be able to validate claims as well as apply the TELUS Health Assure Claims Drug Utilization
Review (DUR) and to determine various individual plan limits such as deductibles, maximums, out-of-pocket accumulator, etc.
TELUS Health and the CPhA3 standard use the following relationship codes. If your software is using the CPhA3 standard or
another approved format, the system will automatically change it to the TELUS Health relationship code.
TELUS CPhA3 Standard
Code Standard Card Description
01 0 The Primary Cardholder: usually an employee of the plan sponsor.
The name of the primary cardholder usually appears on the card.
02 1 Spouse of the Primary Cardholder: in some instances, the name of the spouse appears on
the card, either secondary to that of the primary cardholder, or by itself. A separate card
may be issued in the name of the spouse alone in such cases as when the spouse goes by
a different surname.
03 2 Dependent Child of the Primary Cardholder: usually a minor up to age 18 or 19 but could
be 20 or older, depending on the terms of the group benefit plan.
04 3 Overage Dependent Child of the Primary Cardholder: is still eligible for coverage because
of full-time education. In some cases, separate cards are issued in the name of the overage
student. Such cards will present themselves with the letters “OA” and an expiry date,
usually the end of the school year.
05 4 Overage Disabled Dependent Child of the Primary Cardholder: is still eligible for coverage
because of a mentally or physically disabling condition. In some cases, separate cards may
be issued in the name of the disabled dependent. Such cards present themselves with
the letters “DD”.
Use of the correct relationship code with the wrong date of birth (DOB) will result in the rejection of the claim. This also applies
when the correct DOB is used with the wrong relationship code. It is essential that both match the information in our system in
order to facilitate payment.
Pharmacy Manual 12
Section 3
TELUS Health Assure Claims
Pharmacy Support Centre
Pharmacy Manual 13
SECTION 3
TELUS Health Assure
Claims Pharmacy Support Centre
Contact Information and Hours of Operation
TELUS Health Assure Claims Pharmacy Support Centre:
1 800 668-1608
Monday – Friday 8:00 am – midnight Eastern Time (EST)
Saturday and Sunday 9:00 am – 8:00 pm (EST)
Public Holidays 12:00 pm – 8:00 pm (EST) *
*The days considered public holidays are indicated at the bottom of the page.
When contacting the TELUS Health Assure Claims Pharmacy Support Centre, please have your 10-digit provider number
available. These phone lines are for pharmacies ONLY. DO NOT give cardholders the TELUS Health Assure Claims Pharmacy
Support Centre telephone number. If cardholders have any questions or concerns, they should contact their Benefits Department
at their place of employment.
Electronic providers do not need to contact the TELUS Health Assure Claims Pharmacy Support Centre to determine eligibility
of a drug, or cardholder eligibility or verify plan parameters prior to submitting a claim. Simply submit the claim and eligibility will
automatically be verified. The TELUS Health Assure Claims Pharmacy Support Centre is unable to confirm eligibility in advance.
The only exception to this is when the pharmacy needs to determine eligibility of compound claims. It is always wise to check
that a compound is eligible before filling a prescription. If you are experiencing a systems problem, please contact your software
vendor.
Holiday Schedule
Holiday Hours of Operation
Family Day (February)9:00 a.m. to 8:00 p.m. (EST)
Good Friday Noon to 8:00 p.m. (EST)
Easter Noon to 8:00 p.m. (EST)
Victoria Day Noon to 8:00 p.m. (EST)
Canada Day Noon to 8:00 p.m. (EST)
Civic Holiday (August) 9:00 a.m. to 8:00 p.m. (EST)
Labour Day Noon to 8:00 p.m. (EST)
Thanksgiving Day Noon to 8:00 p.m. (EST)
Christmas Eve 8:00 a.m. to 8:00 p.m. (EST)
Christmas Day Noon to 8:00 p.m. (EST)
Boxing Day Noon to 8:00 p.m. (EST)
New Year’s Eve 8:00 a.m. to 8:00 p.m. (EST)
New Year’s Day Noon to 8:00 p.m. (EST)
Pharmacy Manual 14
Section 4
General Policies and Procedures
Pharmacy Manual 15
Section 4
General Policies and Procedures
Procedures
Validation of electronic claims
Electronic submission offers the advantage of immediate verification of cardholder eligibility and instant processing of each
transmitted claim. It is at all times the responsibility of the pharmacy and the dispensing pharmacist to ensure that:
The cardholder (or the authorized dependent of the cardholder) presents a valid TELUS Assure Claims Card, and the pharmacist
verifies the cardholder identification, including name, date of birth and relationship code.
The cardholder has a valid prescription (abides by provincial regulations and TELUS Health policies, including
regulations on expiration limits on prescription authorizations) from an authorized prescriber.
NOTE: Any online claims found to have been inaccurately submitted under a valid TELUS Assure Claims Card for a
cardholder who does not have coverage under that benefits card, will be charged back to the pharmacy.
Rejected claims are accompanied by an explanation of the reason for rejection. Pharmacies have 7 days from the dispensing date
to submit or re-submit the claim electronically.
Paper claims
Please be advised that the pharmacy will not be reimbursed for paper claims. Only the cardholder may receive reimbursement
from a manual claim.
Incorrect date of birth
TELUS Health uses the date of birth as one of our key identifying features. As such, it is imperative that the pharmacist enters the
correct date of birth to ensure the proper identity of the individual using the TELUS Assure Claims Card. If the Support Centre gave
out this information, it would compromise the integrity of the identification process.
The TELUS Health Assure Claims Pharmacy Support Centre is allowed to confirm whether the birth date you have on file is the
same as that supplied to TELUS Health by the insurance carrier. If the cardholder confirms that the birth date you have on file is
correct but it differs from our cardholder information, then the cardholder must contact his or her employer in order to rectify the
situation. The insurance carrier will inform TELUS Health of the revised information shortly after receiving notification of the required
change from the employee.
If this situation arises and the cardholder cannot wait for the information to be corrected (it may take a few days), the cardholder
should pay and submit the receipt to TELUS Health for direct reimbursement.
Pharmacy Manual 16
Claim void
Occasionally, a transaction may need to be processed at a different date from the original dispense date. The dispense date must
reflect the actual supply date. Any claim transmitted electronically beyond the 7-day limit will be rejected as “claim too old”. The
pharmacy can collect cash from the cardholder who will then submit the receipt to their insurance carrier for reimbursement.
The claim void (reversal) transaction is used to cancel or void a claim that has been successfully processed through TELUS Health.
Most pharmacies have the capability to void claims up to ninety days after the dispense date. Should you find that TELUS Health
was charged for a claim that was never received by the cardholder, or you have a claim which needs to be voided and falls outside
of this 90-day void window, or you are having difficulties in voiding a claim within the 90-day void window, please complete the
“Adjustment to Account” form located at:
http://www.telushealth.com/docs/assure-claims/adjustment-to-account.pdf
Please note that the 90-day window is available for voiding a claim only, resubmissions for prescriptions dispensed outside the
7-day resubmission window will not be accepted electronically.
Alternatively, you may contact the TELUS Health Assure Claims Pharmacy Support Centre for assistance. The manual reversal will
be processed and a notice will be sent to your pharmacy indicating the date on which the amount outstanding will be deducted
from your daily claims total. It is important to retain these notices for account reconciliation.
Claim Retransmission Requests
TELUS Health allows requests for retransmission of claims that are accidentally voided. A “window” may be opened for the
pharmacy to retransmit the claim online if the claim is voided outside the TELUS Health seven-day retransmission window.
In order for TELUS Health to review your retransmission request, you are asked to fill out all fields and provide documentation
required as indicated on the Health Benefits Management ‘Request for Claim Retransmission’ form. Be aware that these requests
are evaluated on a case-by-case basis. In addition, no open window will be authorized for deferred payment, card termination,
same-day voids, rejected claims and non-pack size unit issues. For more information, refer to ‘Claims Retransmission’ under
Pharmacy forms at:
http://www.telushealth.com/docs/assure-claims/claim-retransmission.pdf
Balancing transactions
Pharmacies are expected to complete some daily balancing transactions to reconcile with the TELUS Health bank deposit.
In order to do this we recommend that you follow this procedure:
1. At the beginning of each day, submit a totals request for the previous business day (net settlement report) to us via EDI.
This report will show you a summary of any applicable transactions.
2. At the end of each day, it is important to submit a daily totals request (claims balance inquiry) to us. This report will show you
the total number of claims submitted, voids submitted and the sum total of the amount to be paid.
This total does not include transactions fees or deposit information. We recommend that you compare this report with a totals
report that is generated from your pharmacy management software to ensure that the two systems balance. Should discrepancies
be found, a more detailed report could be obtained from your pharmacy management software to assist in finding the error.
Should it be necessary to void a claim and re-send it, it should be dealt with immediately. The Pharmacy Support Centre will also
be available to assist you with the same day discrepancies. If a detailed report is requested on paper, a processing charge may
apply.
Note: For Western provinces, TELUS Health operates on Eastern Time (ET). Claims processed after midnight ET will show up in
the next day’s totals.
Pharmacy Manual 17
Pharmacy payment options
Next day payment: Payment directly into the Provider’s Authorized Account value dated for the next banking day for a
transaction fee of $0.20 per paid claim.
Twice a month payment: Payment directly into the Provider’s Authorized Account for a transaction fee of $0.10 per paid
claim. For transactions submitted for processing between the 16th and the end of each calendar month, the payment will be
deposited into your account on the first available banking day after the 1st of the following month. For transactions submitted for
processing between the 1st and the 15th of each calendar month, the payment will be deposited into your account on the first
available banking day after the 16th of the month.
Payment 30 days transaction date: Payment directly into the Provider’s Authorized Account value dated for the next available
banking day after 30 days for transaction submitted for processing at no cost. This is not a once a month lump sum payment,
this is a daily deposit 30 days after the transaction date.
TELUS Health has the right to adjust from time to time the transaction fees shown in the confirmation letter, subject to a 30 days
notice to the Provider. The Provider has 14 days from the date of the notice of change to change the payment option in effect at
that time or to cancel the Agreement; otherwise, the services will be charged according to the new rates as of the effective date.
Pricing
Determination of prescription pricing
Pricing policies vary from province to province and therefore regional differences between pharmacies may occur. Some payment
schedules may be based on the usual and customary dispensing fee of a pharmacy, and others on a negotiated fee for all
pharmacies within a province.
Despite these differences, one common rule applies:
The total amount charged shall not exceed the amount that would be charged to a cash-paying customer or other
private pay direct cardholder.
This ensures that all insurance carriers are competing on a level playing field and reduces the incentive for them to direct the
cardholder to lower cost pharmacies.
For all claims submitted to TELUS Health, no balance billing is allowed for differences between your ingredient cost and that
allowed by the TELUS Health price file, where TELUS Health is the primary payer (except in circumstances outlined in the
section What Can Be Charged to Cardholders).
If you have a cardholder who has a deferred payment plan, the same principle applies. You cannot collect from your cardholder
the difference between your ingredient cost and that allowed by the TELUS Health price file.
For the e-sampling program, you receive payment from the participating pharmaceutical manufacturer(s) via the electronic
adjudication system.
When a claim is submitted, our adjudication system bases payment to you on your usual and customary professional fee and on
our price files of drug costs. Our price files are based on a number of reliable sources.
Part of every Provider Agreement with TELUS Health is the acknowledgment that you will accept our adjudicated cost payment
and will not charge the cardholder any excess amount. (Please see What Can be Charged to Cardholders.) Failure to comply with
any TELUS Health policies may result in revocation of your provider number(s) with a possible blackout period where you are not
permitted to reapply for a provider number with TELUS Health.
In the event that your actual acquisition cost exceeds the amount allowed by our system, you can contact our TELUS Health
Assure Claims Pharmacy Support Centre at 1 800 668-1608 and arrange to fax us the most recent invoice supporting your claim
to 1 866-840-1509. For provinces where the payment schedule is based on Manufacturer List Price (MLP), pricing adjustments
are allowed only when the MLP exceeds the amount allowed by our system. Please reference the claim that was affected
and include your provider number. Any invoice which is submitted must be received within 7 days of the dispense date of the
prescription to be adjusted online. Please note, only adjustments of $2.00 or more per DIN will be considered.
Pharmacy Manual 18
In the event a manufacturer decreases their price for a product and you have stock with the previous higher cost, please contact the
manufacturer directly, as TELUS Health is not responsible for manufacturer price decreases. Furthermore, if a generic product is on
backorder, the pharmacy is responsible for checking all available suppliers for stock, or obtaining another generic interchangeable
product before submitting for the brand name. If all generic interchangeable products are temporarily unavailable, then brand name
submissions will be honoured. However, once the generics are available, brand name claims will be cutback to generic pricing.
Keeping a level playing field
EDI Pay-Direct Drug Plans are an increasingly popular employee benefit that is advantageous to both your pharmacy and your
customers. The concept that EDI cardholders should be charged no more than your regular price (i.e. should not be discriminated
against just because they carry the TELUS Assure Claims Card) is critical to its success. This includes charges for diabetic
supplies and oral contraceptives where reduced dispensing fees often apply. The pharmacy should bill TELUS Health EDI
cardholders no more than it would charge cash paying customers or other private pay direct cardholders. Your contract with us
includes this as a requirement.
This also means that if you make any special deals with any pay-direct network, you must apply the same pricing concessions to
TELUS cardholders. We provide pharmacies with a level playing field with respect to competition. In turn, our agreement with your
pharmacy assures that our affiliated insurance carriers are accorded the same cost benefits as you provide our competitors.
Note: This does not preclude you from entering into preferred provider arrangements with single plan sponsors or industry based
associations (Trade Associations).
What can be charged to cardholders
Most plans have various forms of co-payment (deductibles, co-pays, co-insurance), which require the cardholder to pay a portion
of the cost of the prescription. Some plans have dispensing fee caps or deductibles equal to the dispensing fee, which limit
the amount paid by the plan for your professional services. Other plans limit payment to the cost of alternative drugs, such as
generics, or to drugs on a controlled formulary.
Please note that the residual amount is subject to the patient’s private plan rules (e.g. deductibles, co-insurance, etc.). For public
to private Coordination of Benefits (COB) claims, TELUS Health would only pay up to the maximum amount the first payer would
pay, as private insurance is intended to supplement coverage.
Under your agreement with TELUS Health, differences in adjudicated prices on claims can only be passed along to the cardholder
under the following circumstances:
Difference between your usual and customary dispensing fee and the maximum dispensing fee paid under the plan (does not
apply in New Brunswick, Newfoundland, Nova Scotia and Prince Edward Island)
Difference in price between a brand name product and a generic, if the cardholder chooses the brand name product, and it has
not been ordered as “No Substitution” by the physician
Difference in cost for a drug covered by a plan that uses maximum allowable cost (MAC) pricing and/or reference based pricing
(RBP) and/or therapeutic equivalents, e.g., a claim for ranitidine being paid based on the cost of cimetidine
Difference in cost for a drug reimbursed by a Custom Carrier Price File (Indicated by Return Code 6028: Maximum Allowable
Cost Paid)
Difference in cost for the extra amount dispensed for quantities filled in excess of the maximum supply allowed on the plan, e.g.,
cardholder requests a 60-day supply, but the plan pays only 34 days at a time
Any deductibles, co-insurances, and other plan limits applied to the claim.
We make every attempt to maintain fair price files, reflecting reasonable purchase prices. The adjudication process will indicate
to you the maximum amount reimbursed by TELUS Health for the drug cost, including eligible mark-up. Other than above
circumstances, if your drug cost submitted exceeds the amount allowed by our adjudication system, you are not allowed to
charge the difference in drug cost to your patient.
Pharmacy Manual 19
Deferred payment plans
A deferred payment program differs from regular pay direct plans in that it provides payment to the insured at a future date based
on a predetermined period of time or dollar threshold as determined by the plan sponsor. The cardholder will present their card
to the pharmacy for processing; the pharmacy submits the claim in “real time” to TELUS Health for adjudication. At this point the
cardholder will be required to pay the pharmacy the entire cost of the claim and will be automatically reimbursed for the portion
of the claim that their plan sponsor is responsible for (total claim minus co-pay and deductible), either by cheque or by EFT.
Payment is generated once the specified period of time has elapsed or the accumulation of claims reaches a specified dollar
threshold. By processing claims electronically, this allows electronic drug utilization review (DUR) to take place. The amount paid
to the pharmacy directly by TELUS Health will always be zero. The message sent is “Deferred Payment: Patient to pay Pharmacy”.
Cardholders are not required to submit their receipts manually to their insurance company. If the cardholder does not collect the
drug within 2 days of the dispense date, please void the claim. This is essential so that a payment is not made to the cardholder
for a drug that has not been picked up from the pharmacy.
Note: If a patient has multiple TELUS Health plans, and the primary plan is a deferred plan, there cannot be an electronic
co-ordination of benefits. The patient must submit any residual portion of their claim manually to their secondary plan.
Government programs
WorkSafe BC (WSBC)
The WorkSafe BC of British Columbia has a specific card for injured workers. The WSBC client benefit card is for cardholder
use only and does not supply benefits for any dependents. WSBC is the primary payer of eligible injured workers’ claims. The
pharmacy should initially send the claims to BC Pharmacare with an intervention code of DE so that the DUR process takes place.
The claim should then be sent to TELUS Health for adjudication.
Please note as a government agency, WSBC is following BC Pharmacare guidelines with respect to pricing and days supply of eligible
medications. WSBC will not reimburse the claimant for any prescription amount in excess of the BC Pharmacare pricing guidelines.
Also note that any portion of a claim not paid online by WSBC (e.g., dispensing fee, drug cost) cannot be charged to the patient
nor coordinated with a secondary private plan.
Ontario Workplace Safety and Insurance Board (WSIB)
The Ontario Workplace Safety and Insurance Board oversees Ontario’s workplace safety education and training system, and
provides disability benefits to workers injured on the job.
The WSIB Drug Benefit Program pays for medication prescribed by physicians for work-related injuries or illnesses. The program
also has an automated online approval and billing system that allows Ontario pharmacies to obtain authorization for worker’s
prescriptions over the Internet and to bill us directly through the system.
Please note that any portion of a claim not paid online by WSIB (e.g., dispensing fee, drug cost) cannot be charged to the patient
nor coordinated with a secondary private plan.
Documentation requirements
For all claims submitted through the TELUS Assure Claims Card system, TELUS Health requires that documentation be available
on all prescriptions.
Authorization for prescriptions
TELUS Health requires an authorized prescription for claims submitted electronically. This includes both prescription requiring
items and OTC items. An authorized prescriber can order a prescription. TELUS Health considers authorized prescribers to be as
follows: physician, surgeon, dentist or other healthcare professional prescriber* in good standing with their governing body. Any
provincial restrictions placed on prescribing practices are followed by TELUS Health (e.g. a specific list of drugs that a practitioner
can prescribe from).
* where provincial laws permit these persons to prescribe
Pharmacy Manual 20
Verbal refill authorizations and verbal prescriptions
For all claims submitted to TELUS Health, it is required that documentation be available on all verbal prescriptions, and verbal
authorizations for refills on both prescription requiring and over the counter (OTC) claims. Verbal prescriptions must be received
from an authorized prescriber (see Authorization for Prescriptions), and must be reduced to writing by the receiving pharmacist or
entered into the computer record as a log/unfill prescription. This documentation must be recorded prior to processing the claim to
ensure there is a reference to verify the prescription claim.
The documentation must include the following:
The date that the authorization was received
The patient’s full name
The drug name, quantity and directions for use
The prescriber’s name
The signature of the receiving pharmacist
The number of refills (if authorized) and the interval between refills (if applicable)
It is also required that all properly completed verbal orders, faxed authorizations, etc., be retained with the prescription hardcopies
for future reference. It is important that pharmacy records are complete and accurate. Records must contain an independent audit
trail. The “piggybacking” of a new authorization onto an existing authorization does not meet this requirement.
Pharmacist Prescribing/Adaptation
Where provincial regulations allows for the pharmacist extended scope of practice, TELUS Health will accept pharmacist prescri-
bed/adapted claims based on plan design coverage.
Continued Care Prescription (CCP)/Prescription Adaptation by a Pharmacist
TELUS Health supports online submission of continued care prescriptions (CCP) authorized by a pharmacist. We understand
pharmacists are required to adapt/prescribe a drug by complying with the provincial prescription adaptation regulations when filling
a prescription. The regulation does not further govern the submission of pharmacist prescribed claims to third party payers. To
minimize any misunderstanding, please follow the claim submission instructions below for all CCP or adapted prescriptions by a
pharmacist.
The CCP documentation must include the following five components:
1. The date of authorization
2. Patient’s full name
3. Drug name, quantity, and direction for use
4. Prescribing pharmacist’s full name, license number and signature
5. Number of refills (if authorized)
For over-the-counter medications, TELUS Health does not accept quantities such as “1 year supply”, “18 month supply” or
“unlimited refills until a prescription expires” without specific directions. Please refer to the section ‘Monthly Maximums’.
For non-specific directions, we require the total quantity authorized in numerical value and the total number of refills (if applicable).
Changing an authorized prescription
Where provincial regulatory bodies require, it is required that documentation be available on all authorized changes to existing
prescription orders. These changes must be received from an authorized prescriber and must be reduced to writing by a pharma-
cist, prior to processing the claim. TELUS requires written documentation from the prescriber to dispense time interval medication
outside of the specified number of days on the original authorization.
Pharmacy Manual 21
Dispensing reduced quantities
Where provincial regulatory bodies require, the patient’s signature must appear on the prescription should a lesser quantity be
dispensed than what was originally prescribed by the authorized prescriber. On claims where a lesser quantity is dispensed due to
plan limitations (i.e. prescribed 200 days but plan limits to 100 day supply), no patient’s signature is required.
Documentation retention
For submission of claims to TELUS Health, it is required that documentation (original written or verbal prescriptions, computer
generated hardcopies – where required by law, forms etc.) pertaining to claims processed using the TELUS Health Assure Claims
Drug Engine must be retained, and available, on all prescriptions; written, verbal, refill authorizations (written or verbal), and OTC
claims. Prescription retention periods must follow your provincial regulations.
No substitution
Where provincial regulatory bodies require, the authorized prescriber prior to processing the claim, in order for TELUS Health to
pay for the cost of the Brand name medication online, must indicate as such in one of the following ways:
1. Handwrite the order for “No Substitution” or initial the stamp in the section provided on the written prescription from the physi-
cian. A pharmacy can verbally verify a “No Substitution” as long it is received and dated prior to the claim being submitted for
payment and is documented according to the TELUS Health documentation requirements.
2. On a verbal prescription, the order for a “No Substitution” must be ordered by the authorized prescriber, and handwritten by
the pharmacist who is recording the verbal prescription, prior to processing the claim.
3. On an electronic or printed prescription the physician must indicate “No Substitution” in the document.
Prescriptions bearing the handwritten notation “No Substitution” on the actual prescription as ordered by the prescriber, may be
eligible for payment above the cost of the lowest priced interchangeable product, when flagged as “N” for “No Substitution” or
Product Selection = “1” (Prescriber’s Choice) for CPhA3 EDI claims.
Pharmacist’s signature/initals required
Where provincial regulatory bodies require, TELUS Health requires the pharmacist’s signature/initials to be present on the
computer-generated hardcopy as confirmation that the claim was indeed dispensed by a pharmacist, and not processed in error.
Prescription not dated
As the date of authorization is needed to determine the expiration of the prescription as a whole, and/or expiration of authorized
repeats, TELUS Health requires this information to be present on all prescription documentation for claims transmitted through the
TELUS Health adjudication system. The date is also required to determine if the authorization was received prior to processing the
claim online.
Policies
Classes of drugs that may have restrictions
Plan sponsors may choose to exclude or restrict access to specific classes of drugs for a group or division and unit. Restriction
may be in terms of dollar value paid in a year or as a lifetime maximum. The most common restrictions (but not limited to) are:
Fertility treatments
Smoking cessation
Preventative vaccines
Antiobesity/Anorexiant
Erectile dysfunction
We have summarized some guidelines on maximum quantities for drugs where the directions do not indicate clear dosing
schedules. Please see Monthly Maximums.
Pharmacy Manual 22
Days supply / early refill
The correct days supply is essential for DUR and accurate adjudication. We understand that it can be difficult when there are no
dosing instructions on the prescription. However, a reasonable estimate is preferable to filling the field with an automatic 30 days.
When receiving a DUR warning for early refill, ensure that at least two-thirds of the previously dispensed supply has been used
before processing the new supply. Please note that TELUS Health DUR checks are done against the cardholder’s entire claim
history, and not limited to claims dispensed from your pharmacy. Should a cardholder require an early refill, for reasons other than
a change in prescribed dosage, they are required to pay cash for the claim, and submit the receipt, along with the reason for the
early refill, to their insurance carrier for payment. If you have concerns about dispensing prescriptions after receiving the warning
message, please contact our Pharmacy Support Centre for clarification.
Additionally, should the cardholder require an amount in excess of the maximum days supply allowed on the plan, they are
required to pay cash for the amount of the prescription in excess of the allowed amount, and submit to their insurance carrier for
payment, along with the reason for the larger supply. These situations include:
Lost medications
Changes between manufacturers (different generic/brand switch)
Vacation supplies
See also Vacation Supply and Replacement Supplies.
Note that in all situations, the pharmacy must consider the amount of medication still on hand with the cardholder before
considering submitting claims for additional supplies.
If you have concerns about dispensing prescriptions after receiving the warning message, contact our Pharmacy Support Centre
for clarification.
Dispensing the same drug more than once in a five (5) day period
If a product, other than an antibiotic, narcotic or controlled drug, is dispensed more than once within a five (5) day period, the
second (and other) claim(s) will be treated as either a balance owing from the original prescription, or a duplicate claim. For a
balance owing, a professional fee may not be claimed as part of this second transaction. If the claim is considered a duplicate
claim of the original prescription, the entire payment for the second (and other) claim(s) will be recovered.
The only exception to this would be if the drug were allowed as part of TELUS Health administered Trial Drug Program.
Vacation supply
Most plans administered by TELUS Health will allow 100 days supply for maintenance drugs. When a cardholder or dependent
requests a supply greater than 100 days, indicating that this represents a vacation supply, the claim can be processed as follows.
The pharmacy can transmit the claim with the correct days supply, TELUS Health will cut back the cost to the allowed days supply
and the pharmacy can have the cardholder pay for the difference. The cardholder must pay for this extra supply and submit a
manual claim to their insurance carrier with an explanation.
Compliance packaging
The use of compliance packaging may be subject to review through the audit process, including consultation with the physician
and/or insurance carrier for appropriateness of use. Please ensure your records include all documentation as to who requested the
compliance packaging.
TELUS Health will only be responsible for the multiple dispensing fees in a given month should the compliance packaging order
be requested by a physician. If the pharmacy or the cardholder is requesting the compliance packaging, then TELUS Health will
only pay for 1 fee in a given month (with the exception of the Trial program). The cardholder would be responsible for paying the
additional fees incurred in that month.
This is done to ensure that TELUS Health is paying for only the additional costs incurred because of a medical necessity
determined by the physician. If a pharmacist or cardholder feels that there is a compliance issue, then discussions with the
prescribing physician should occur regarding their concerns. At that point, the physician would determine the best course of
action to take for optimum cardholder compliance.
Pharmacy Manual 23
Replacement supplies (lost/stolen/spoiled prescriptions)
If a medication is lost/stolen/damaged/spoiled the cardholder must pay for the replacement prescription and submit the receipts to
their insurance company with a note of explanation. The pharmacist is not to submit the claim to TELUS Health a second time or
as an early refill.
Procedure for submitting claims for diabetic supplies (excluding diabetic devices)
Use the pseudo-DIN (PIN) customarily assigned by your provincial formulary or by TELUS Health for specific diabetic items. Please
refer to: http://www.telushealth.com/Solutions-for-pharmacists/download-drug-claims-documents for the most up to date
list of diabetic PINs, or call the Pharmacy Support Centre for a hard copy of this list.
Reimbursement handling for free and discounted meters and training fees
The pharmacy is responsible for payment of all income and other taxes in respect of payments made to the pharmacy for
reimbursement of free and discounted meters and training fees. By seeking reimbursement for free meters, the pharmacy states
that the meters sought for reimbursement were purchased by the pharmacy for a price approximating full market value and were
provided free of charge to the patient, and no other form of reimbursement was sought from any other source in respect of those
meters. By seeking reimbursement for discounted meters as prescribed by the meter manufacturer, the pharmacy states that the
meters sought for reimbursement were purchased by the pharmacy for a price approximating full market value and were provided
to the patient pursuant to the prescribed discount, and no other form of reimbursement was sought from any other source in
respect of those meters. All warranty cards must be completed and sent to the meter manufacturer or third party on behalf of and
as instructed by the manufacturer. By seeking reimbursement for training fees, the pharmacy states that the number of patients
indicated by the pharmacy as receiving training is accurate and no other form of reimbursement was sought for the training.
Allergy products
Allergy products on the market that have an assigned DIN, but are manufactured specifically for individual cardholders, are not to
be transmitted electronically to TELUS Health. Due to the individualized nature of these products it is not possible for our system
to maintain accurate pricing. These products are not online benefits for TELUS Assure Claims cardholders. Please collect cash
payment from your patient and have them submit the receipt manually. Allergy serums that are not manufactured specifically for
individual patients (i.e. Pollinex R®) are eligible for online submission.
Pharmacy Manual 24
Monthly maximums
TELUS Health has summarized some guidelines on maximum quantities for drugs where the directions do not indicate clear
dosing schedules (e.g. “PRN” or “Use as directed”). These maximums are limitations in drug plan coverage. The following list
comprises the most common requests.
As of November 2012
Allergy Therapy - Injectable
Epipen®, Twinject® (epinephrine) Injection 4 kits or devices for a 30 day supply with a refill only after a
device has been used or expires
Anti-Migraine Therapy
Amerge® (naratriptan) Tablets 12 tablets every 30 days
Axert® (almotriptan) Tablets
Frova® (frovatriptan) Tablets
Maxalt® (rizatriptan) Tablets, RPD
Relpax® (eletriptan) Tablets
Zomig® (zolmitriptan) Tablets
Imitrex® (sumatriptan) Tablets 12 tablets every 30 days
Imitrex® (sumatriptan) Injection 8 injections every 30 days
Imitrex® (sumatriptan) Nasal Spray 12 bottles of nasal spray every 30 days
Diabetic Testing Strips
Any brand of test strip used to test glucose in the blood. 600 strips every 100 days (testing up to 6 times per day)
Narcotic Analgesics
Stadol® (butorphanol) Nasal Spray 4 bottles of nasal spray every 30 days
Ophthalmic Anti-Allergic Agent/Antihistamine Drops
Alocril® (nedocromil) 10 ml per month
Alomide® (lodoxamide)
Emadine® (emedastine)
Livostin® (levocabastine)
Patanol® (olopatadine)
Zaditor® (ketotifen)
Oral Erectile Dysfunction Therapy
Cialis® (tadalafil) Tablets Generally covered by exception;
Levitra® (vardenafil) Tablets 12 tablets every 30 days if applicable
Viagra™ (sildenafil) Tablets
Cialis® (tadalafil) Tablets – 2.5 mg and 5 mg strengths only Generally covered by exception;
30 tablets every 30 days if applicable
Miscellaneous
Glucagon Injection Kit 2 vials per month
Pennsaid® (diclofenac) 540 ml per month
Note: The maximums also apply to generic versions of the brand drugs listed above.
Pharmacy Manual 25
Submission & eligibility guidelines for compounds
A compound is a product that a pharmacist must make by mixing two or more ingredients, and when they are combined, become
a preparation that is not commercially available. A compound can be in the form of liquid, capsules, cream, ointment, IV bag, etc.
Compounds are sometimes referred to as mixtures or extemporaneous mixtures.
Submission rules
Whenever possible, we require that you transmit compound claims using the DIN of the principle prescription-requiring ingredient
in that compound (if applicable). This will ensure an online eligibility check of the DIN/PIN you have transmitted. An example would
be hydrocortisone 1% cream and clotrimazole cream, compounded in equal parts – please transmit the compound with the
hydrocortisone cream DIN and the appropriate compound code. The hydrocortisone cream is a prescription-requiring ingredient
and is likely to be eligible on most plans, whereas the clotrimazole cream is OTC and not eligible on most plans. If your compound
contains no prescription-requiring ingredients, please transmit using one of the ingredient DINs. If you must use a general
compound PIN (e.g. 00999999, 00900710) to submit a claim, we strongly recommend that you contact the TELUS Health
Assure Claims Pharmacy Support Centre to confirm eligibility.
Duplicating a commercially available product
If a compound mimics a commercially available product, the compound will not be covered. If the commercially available product
is out of stock, a temporary exception may be granted to allow for the compounding of the product until the commercially available
product is available. If you have any questions regarding compound eligibility contact the TELUS Health Assure Claims Pharmacy
Support Centre at 1 800 668-1608
Unlisted compound codes
0 = Compounded topical cream 5 = Compounded internal powder
1 = Compounded topical ointment 6 = Compounded injection or infusion
2 = Compounded external lotion 7 = Compounded eye/ear drop
3 = Compounded internal use liquid 8 = Compounded suppository
4 = Compounded external powder 9 = Other compound
All compounds must be submitted with the correct corresponding unlisted compound code. There are some exceptions to this
rule, e.g. Remicade™, methadone. See Appendix 5 for some common compounds that have special PINs and submission rules.
Ineligible compounds
A commercial product is available in the same strength
The primary ingredient is not covered under the cardholder’s plan, i.e.
OTC’s
Investigational products
Natural products
Homeopathic products
The product is for cosmetic use
The product contains an ineligible base/ingredient (see lists below for ineligible drugs and ineligible bases) or is in an ineligible
format.
Pharmacy Manual 26
Ineligible Bases, Ingredients and Formats: The following chemicals/drugs/ formats (but not limited to those listed) are not
eligible on any of our plans, even if combined with a prescription-requiring medication or with a product considered to be an
eligible benefit.
Ineligible bases
Benoquin® Lustra™ (entire product line) Rosacure®
BioBase G™ Neostrata® (entire product line) Solage®
Eldopaque® Neutrogena® (selected products) Solaquin®
Eldoquin® Porecelana® sunscreens (all product brands)
glycolic acid Rejuva® Ultraquin®
Glyquin® Renova® Viquin®
Kinerase® retinol vitamin E cream
La Roche-Posay® (entire product line) Reversa® (entire product line)
Ineligible ingredients
aminophylline in a topical base DMSA (dimercaptosuccinic acid) Mercurochrome®
ammoniated mercury DNCB methylcellulose E4M
arsenic (dinitrochlorobenzene) minoxidil (any strength)
azaleic acid (Used for Hair Loss) Evening Primrose Oil Perio Plus®
benzoin tincture/Friar’s Balsam finasteride (compounded) Peru Balsam
bichloracetic acid gentian violet pregnenolone
coumarin glycolic acid secretin
DCP (diphencyprone/ histamine/caffeine (Procarin®) titanium dioxide
diphencyclopropenone) hydroquinone triamcinolone (used for hair loss)
DHEA (dehydroepiandrosterone) kojic acid tri-iodo-L-thyronine – topical
DMAE (dimethylaminoethinol) magnesium dicitratem vitamin K topically
DMPS (dimercaptopropanesulphonate) mandelic acid yohimbine
Ineligible forms/formats
Regardless of the drugs or chemicals added, compounds made into the following dosage forms (but not limited to those listed)
are not eligible under all plans:
gummies pre-filled syringes timed release products
lollipops sustained release products troches
lozenges slow release products
An ineligible ingredient/base/form may be covered by individual cardholder by exception only. Please confirm with the
TELUS Health Assure Claims Pharmacy Support Centre before submitting claims under these circumstances.
Eligible compounds
Compounds are eligible if the primary active ingredient is covered on the cardholder’s plan.
Important: Even though an eligible prescription requiring DIN/PIN may be accepted online, if it has been added to a compound
containing an ineligible ingredient or base as listed below or is in an ineligible format, the compound will be deemed ineligible and
charge backs will apply.
Pharmacy Manual 27
Powder to Liquid Suspension/Emulsion (Internal/External Use)
Quantity Range No. of Ingredients Allowable Time
0 to 15 grams/mls 2 5 min
3 6 min
4 8 min
5 10 min
6 12 min
16 to 25 grams/mls 2 7 min
3 8 min
4 10 min
5 12 min
6 14 min
26 to 50 grams/mls 2 10 min
3 12 min
4 16 min
5 20 min
6 24 min
51 to 100 grams/mls 2 12 min
3 14 min
4 18 min
5 22 min
6 26 min
101 to 200 grams/mls 2 14 min
3 16 min
4 20 min
5 24 min
6 28 min
201 to 300 grams/mls 2 16 min
3 18 min
4 22 min
5 26 min
6 30 min
301 to 400 grams/mls 2 18 min
3 20 min
4 24 min
5 28 min
6 32 min
401 to 500 grams/mls 2 20 min
3 22 min
4 26 min
5 30 min
6 34 min
Reimbursement time guidelines for compounds
TELUS Health receives inquiries from pharmacies regarding the allowable time charges that can be charged to TELUS Health
when submitting compounds. Depending on the mixture preparation, please refer to the appropriate chart below when
submitting claims.
End Result Equals a Cream/Ointment/Lotion Preparation
Quantity Range No. of Ingredients Allowable Time
0 to 15 grams 2 5 min
3 6 min
4 8 min
5 10 min
6 12 min
16 to 25 grams 2 7 min
3 8 min
4 10 min
5 12 min
6 14 min
26 to 50 grams 2 10 min
3 12 min
4 16 min
5 20 min
6 24 min
51 to 100 grams 2 12 min
3 14 min
4 18 min
5 22 min
6 26 min
101 to 200 grams 2 14 min
3 16 min
4 20 min
5 24 min
6 28 min
201 to 300 grams 2 16 min
3 18 min
4 22 min
5 26 min
6 30 min
301 to 400 grams 2 18 min
3 20 min
4 24 min
5 28 min
6 32 min
401 to 500 grams 2 20 min
3 22 min
4 26 min
5 30 min
6 34 min
Pharmacy Manual 28
Liquid to Liquid Injections or Reconstituted Liquid - Vials
Nbre d’ingrédients Temps admissible
2 10 min
3 12 min
4 14 min
5 16 min
End Result Equals a Capsule Form
The allowable time plus an additional 45 min/100 capsules
Reminder: Any compounded SR products are not covered.
No. of Ingredients Allowable Time
1 3 min
2 5 min
3 7 min
4 9 min
5 11 min
Liquid to Liquid Compounds
Quantity Range No. of Ingredients Allowable Time
0 to 500 mls 2 2 min
3 3 min
4 4 min
5 5 min
6 6 min
501 to 1 000 mls 2 4 min
3 5 min
4 6 min
5 7 min
6 8 min
1001 mls + 2 6 min
3 7 min
4 8 min
5 9 min
6 10 min
Capsules/Tablets Compounded to Liquid
Oral Suspension
Quantity Range No. of Ingredients Allowable Time
Up to 15 tabs 2 15 min
/caps 3 20 min
4 25 min
5 30 min
Powder to Liquid Injection - Vials
No. of Ingredients Allowable Time
2 10 min
3 12 min
4 14 min
5 16 min
Additional notes:
Compounding Topical Syringes :
We allow time charge per number of ingredients plus an additional 2 min per syringe.
Compounding IV preparations and Cassettes :
We allow 3 minutes per mini bag
We allow 24 minutes per 100 ml cassette
We allow 18 minutes per 50 ml cassette
Pumpbags are priced the same as cassettes
End Result Equals a Suppository Form
The allowable time plus an additional
60 min/100 suppositories
No. of Ingredients Allowable Time
1 3 min
2 5 min
3 7 min
4 9 min
5 11 min
Pharmacy Manual 29
Provincial Compound Fee Guidelines
Province Fee
British Columbia A compound time charge of a pre-established amount per minute, plus a regular dispensing fee.
Alberta Only a regular dispensing fee can be charged if the compound requires less than 7 minutes
preparation time. If a compound requires more than 7 minutes preparation, a regular dispensing
fee plus an addition pre-established amount per minute for each minute in excess of seven (7)
minutes can be charged.
Saskatchewan A compound time charge to a pre-established amount per minute, plus a regular dispensing fee.
Manitoba A compound time charge to a pre-established amount per minute, plus a regular dispensing fee.
Ontario A compound time charge to a pre-established amount per minute, plus a regular dispensing fee.
Quebec A compound time charge based on usual and customary dispensing fee.
New-Brunswick Compounding time is a flat rate of 1.5 times the usual and customary dispensing fee submitted
in the compounding charge field. No regular dispensing fee can be charged. Dispensing fee field
is left blank.
Nova Scotia Compounding time is a flat rate of 1.5 times the usual and customary dispensing fee submitted
in the compounding charge field. No regular dispensing fee can be charged. Dispensing fee field
is left blank.
Newfoundland Compounding time is a flat rate of 1.5 times the usual and customary dispensing fee submitted
in the compounding charge field. No regular dispensing fee can be charged. Dispensing fee field
is left blank.
Prince Edward Island Compounding time is a flat rate of 1.5 times the usual and customary dispensing fee submitted
in the compounding charge field. No regular dispensing fee can be charged. Dispensing fee field
is left blank.
Northwest Territories, Compounding time is a flat rate of 1.5 times the usual and customary dispensing fee submitted
Yukon and Nunavut in the compounding charge field. No regular dispensing fee can be charged. Dispensing fee field
is left blank.
* All guidelines are subject to modifications based on a number of factors including the usual and customary practices in
different provinces.
Note:
1. Pharmacies in Atlantic Canada are not permitted to charge a regular dispensing fee on top of the compound fee.
2. In Ontario for provincial coordination of benefits (COB), TELUS Health follows ODB allowable time charges.
If you have any questions on how to transmit a compound claim, or if you need to determine compound eligibility, please do not
hesitate to contact the TELUS Health Assure Claims Pharmacy Support Centre. For compound verification for a cardholder, you
will be asked to provide the following information:
Cardholder’s name
Cardholder’s drug card information
Cardholder’s date of birth
ALL compound ingredients with their strength (if applicable) and/or quantity
If the compound is deemed eligible, the agent may provide you with a compound PIN to submit the claim. Please note that
all claims for compounds are subject to review by the TELUS Health Audit Department. Any compound claims determined to be
ineligible or submitted for compounding charges (time and/or charge per minute) in excess of ACCEPTED PHARMACY PRACTICE
will be adjusted or charged back to the pharmacy.
Pharmacy Manual 30
Section 5
Drug Utilization Review (DUR)
Pharmacy Manual 31
Section 5
Drug Utilization Review (DUR)
DUR Overview
Healthcare professionals and drug manufacturers all agree on the importance of consumer education and health awareness.
Many patients are striving to learn more from their healthcare professionals about the medications they take. However, some
patients may have inexact recollection of their past drug regimens, so the advice provided may be based on limited informa-
tion. In addition, while many patients only fill their prescriptions at one pharmacy, there are an increasing percentage of patients
that frequent multiple pharmacies for convenience. This probably represents a high number of chronic medication users. These
patients may visit several healthcare professionals for different problems and these prescribers may not always be aware of all the
medications the patient has taken. Our TELUS Health DUR service provides an answer to this problem.
DUR - How it works
When a pharmacist transmits a claim, the adjudication engine accesses the centralized database to search for potential problems
relating to medications. It references each specific cardholder’s drug claim history, and checks the submitted medication against
any medications dispensed within the last 100 days processed through our system from any pharmacy in Canada. The DUR is
performed at the point of service and the result is sent back instantly. The criteria for these checks come from First DataBank, an
international organization that provides drug information to governments, insurers, hospitals and other Pharmacy Benefit Mana-
gers. First DataBank, a division of The Hearst Corporation, is the world’s leading provider of health information. First DataBank
employs a large staff of clinical experts that include clinical pharmacists, physicians and a world-renowned independent panel of
clinical drug experts. The TELUS Health interaction drug database is updated every 2 weeks from First DataBank. As new scienti-
fic information about drug interactions becomes available, our DUR responses reflect them.
DUR Checks
Drug Age Indicates if the product may be harmful if the cardholder is a child or a senior.
Drug Gender Alerts the pharmacist if this medication is intended for use by a member of the opposite gender only.
Drug Interaction Looks for other known active ingredients that may interact adversely with ingredients in
the current medication.
Minimum/Maximum Determines if the prescribed directions (based on the quantity and the days supply submitted)
Dosage corresponds to the dosage established by the drug manufacturer.
Refill Too Soon/ Indicates if a maintenance drug prescription is being refilled too early or too late, providing
Too Late a strong indication of non-adherence or perhaps stockpiling.
Therapeutic Checks if the medication dispensed is similar to others in the cardholder’s drug history.
Duplication Drug class determines therapeutic duplications.
Pharmacy Manual 32
First DataBank identifies drug interactions that have been reported in the scientific literature and ranks them by potential
significance levels.
Level 1 There is a possibility of significant interaction that is well documented in clinical studies and actual case reports
Level 2 This interaction is of moderate significance
Level 3 A contraindication that is only described in the manufacturer’s prescribing information with no reports or
publications from the scientific community will be considered to be a level 3 interactions.
Drug interactions
Insurers have the flexibility to select the type of response (reject of claim or warning message only) required for each type of check.
As a general rule, when the DUR detects a Level 1 drug interaction, the claim will be rejected.
Important: We request that all pharmacies transmit the proper days supply as per the medication directions when submitting
claims. For prescriptions with directions “take as needed” and “take as directed”, you must base the days supply on a
reasonable estimate. (See Monthly Maximums in Section 4 General Policies and Procedures.)
When the days supply of medication transmitted is inaccurate, the following can result:
Inaccurate refill too late/early messages
Inaccurate dosage too high or too low
Inaccurate minimum/maximum dosage check
Transmitting the proper days supply of medication greatly reduces the number of inappropriate messages.
What to do when the DUR rejects a prescription?
For the majority of our policies, pharmacies will receive a warning message on potential duplicate therapies. For example, this may
occur with a cardholder requiring several strengths of levothyroxine or warfarin. Some policies may have selected to reject claims
that are potential duplicate therapies. If the therapy is appropriate, you may override the reject code with the most appropriate
intervention code from the following list:
Code Description
UA Consulted prescriber and filled Rx as written
UB Consulted prescriber and changed dose
UC Consulted prescriber and changed instructions for use
UD Consulted prescriber and changed drug
UE Consulted prescriber and changed quantity
UF Patient gave adequate explanation. Rx filled as written
UG Cautioned patient. Rx filled as written
UI Consulted other source. Rx filled as written
UJ Consulted other sources. Altered Rx and filled
UN Assessed patient. Therapy is appropriate
TELUS Health is aware that while computer programs can facilitate screening, it will never replace the pharmacist’s knowledge in
managing problems relating to the cardholder’s drug therapy. For questions about a drug interaction message, the pharmacy can
contact the TELUS Health Assure Claims Pharmacy Support Centre.
Pharmacy Manual 33
Section 6
Audits and the Audit Department
Pharmacy Manual 34
Section 6
Audits and the Audit Department
It is TELUS Health mandate to handle the insurer’s funds with integrity and to confirm that pharmacies are paid in accordance with
the insurers plan and its policies. The accuracy and validity of each claim is critical, thereby requiring a comprehensive approach to
auditing claims.
All claims submitted through TELUS Health are subject to audit by our Audit Department, and pharmacies will be contacted if a
review of a claim is necessary. Successful adjudication of a claim does not prohibit a future audit of that claim. If during an audit it
is found that inappropriate information or processes have resulted in a successful adjudication result, then TELUS Health retains
the right to recover payments previously made. When a pharmacy receives a Notice of Adjustment from TELUS Health, please do
not void any of the claims contained within the Notice. Voiding claims will result in multiple deductions of funds from the Provi-
der Account. If you have any questions related to the Notice of Adjustment, please contact the auditor who conducted the audit
PRIOR TO the deduction date indicated in the Notice.
Due to privacy and confidentiality, pharmacies are prohibited from sharing or forwarding any audit claims information and/or the
Notice of Adjustment to other parties as per the Provider Agreement signed by the pharmacy and TELUS Health.
An “audit” is a follow-up to the electronic adjudication process. Audits are conducted for four main reasons:
To ensure consistent & accurate claims submissions by the pharmacy community.
To ensure system integrity.
To detect and report possible fraud issues and Cardholder drug abuse/misuse issues.
To clarify with the pharmacy community on the proper ways to submit claims online (billing practices), in accordance with
TELUS Health Policies and Procedures Manual and TELUS Health Pharmacy Updates.
There are several different types of audits conducted by TELUS Health. On-site audits for example, are based on an in-depth
investigation of a single pharmacy’s claim submission practices. Desk audits, telephone audits, compound audits, and survey
audits are also conducted on a routine basis to monitor national claim activities. By contractual agreement with TELUS Health, it
is expected that all pharmacies will adhere to the policies and procedures as outlined in this manual, and in any published TELUS
Health Pharmacy Updates. In turn, the insurance carriers contractually obligate TELUS Health to take appropriate action where a
pharmacy fails to comply with the policies and procedures herein. Any inquiries regarding our audit policies and procedures should
be referred to the Audit Department at 905 602-7350 (TELUS Health main line), or toll-free at 1 800 668-1608 (Pharmacy Support
Centre).
Pharmacy Manual 35
Overview: on-site pharmacy audits
TELUS Health on-site pharmacy audits are conducted routinely, and are part of the contractual agreement TELUS Health has with
our insurance carriers. This type of audit is based on an in-depth investigation of a single pharmacy’s submission practices to the
TELUS Health Assure Claims Drug Engine.
The Auditor may contact the pharmacy in advance providing the pharmacy with a date and time for the audit, as a professional
courtesy. Rare instances may occur when advanced notification of the audit is not possible. On-site pharmacy audits will vary
in duration, determined by the number of claims selected for review, and the accessibility of the supporting documentation
(prescriptions, computer generated hardcopies, etc) for those claims. Availability of pharmacy staff to locate the required
documentation will help to expedite the on-site portion of the audit. Permitting pharmacy staff to retrieve the required supporting
documents ensures our audit personnel will only be looking at TELUS Health claims. TELUS Health Auditors are responsible for
maintaining the confidentiality of the information they collect, and are held accountable for breaches in this standard of conduct.
The provision of a suitable working space for the Auditor will minimize any interruption of the pharmacy’s daily routine. The on-site
portion of the pharmacy audit is needed to gather information for review once back at the TELUS Health offices. Information is
generally not reviewed at the pharmacy.
If during an on-site pharmacy audit, the pharmacy is unable to produce supporting documents (prescriptions, computer generated
hardcopies, etc) as requested by the Auditor, then it is at the discretion of the Auditor whether the original documents, faxed or
photocopied and mailed at a later date, will be acceptable as part of the review. Please note, that the auditor is not obligated to
accept additional documentation, which was not originally available on request. Please note that “reprinted” hardcopies generated
at or around the time of the audit, or prescription authorizations received after claims submission, will not be accepted as original
supporting documentation.
Once the review portion of the pharmacy audit has been completed (usually within 6-8 weeks), the pharmacy will receive a letter
from the Auditor outlining any issues that were discovered during the audit. The letter may also include a list of transactions for
which payment is being fully or partially recovered, due to non-compliance with TELUS Health policies and procedures.
Our Auditors, both pharmacy technicians and licensed pharmacists, are well-qualified industry experts who have extensive
industry experience, both in pharmacy and in the third-party adjudication fields. As TELUS Health audits claims from all
pharmacies across Canada, our Auditors are well versed on each of the province’s pharmacy legislation, as well as the federal
legislation existing in Canada overall.
Fraud tips
The TELUS Health Audit Team works closely with several groups, including Pharmacy Associations, in order to combat fraud.
Should you become aware of any issues that breach TELUS Health Policies, or potential fraud related issues, please contact us at
1 800 668-1680 or via e-mail at anti-fraud@telus.com. Any information received will be treated with the highest level of confiden-
tiality, and can be made completely anonymous.
Pharmacy Manual 36
Section 7
Co-ordination of Benefits
Pharmacy Manual 37
Section 7
Co-ordination of Benefits
Provincial Co-ordination of Benefits (COB)
TELUS Health coordinates claim payment with most provincially administered plans unless the province is payer of last resort.
All appropriate claims must initially be submitted to the Provincial government for payment where applicable. Please use the
intervention code DA.
The above is the basic submission rule for the co-ordination of benefits with a provincial plan. However, please be advised some
insurance carriers will decide that they do not wish to incur provincial deductibles. These plans may retain the old rules regarding
provincial liability. For example, a group in Ontario may wish to continue the practice of not paying for any portion of a claim for a
senior on a drug covered by Ontario Drug Benefit (ODB). These groups would ignore the “Previously Paid Amount” and not pay
any portion of the drug. Whatever shortfall occurs would have to be collected from the cardholder. It is important that you pay
close attention to the paid amount on the transaction received back from us; this is the amount covered by the private plan.
Private Co-ordination of Benefits (COB)
Pharmacies can submit residual claims to secondary private plans for consideration. Use the intervention code DB.
Where applicable, the total cost that can be covered by TELUS Health as a secondary payer, shall never exceed
the AAC plus the appropriate provincial mark-up allowed by TELUS Health price file, which includes the amount
already covered by the primary payer.
If a group has opted out of this program then the COB claim will reject with the message “Not Eligible for COB” and CPhA3 code
KK. The cardholder may still be able to submit the balance as a paper claim.
Limited use drugs for Ontario seniors with private drug plan coverage
Similar to regular benefits under the Ontario Drug Benefit (ODB) Program, eligible claims for Limited Use (LU) drugs should be
submitted to the public plan before they are submitted to private plans. Please ensure that seniors covered under ODB meeting
the LU criteria have their claims submitted to the public plan before coordination with the cardholder’s private plan. In cases where
the cardholder does not meet the specific ODB criteria for LU drug coverage, the claim may be submitted to the private plan as
first payer.
Spouses – 65 or over (Alberta)
In Alberta, various rules for cardholders 65 years old or over and their dependents occur. If the cardholder or spouse is over the
age of 65, dependents are generally covered on the provincial plan. This means that TELUS Health is the second payer in this
case. If you receive a message stating, “Din Covered by other”, this means that we are the second payer. Reverse the claim and
send it to the appropriate provincial drug plan first.
Pharmacy Manual 38
Manitoba and Saskatchewan: Provincial Registration Management Program
The Provincial Registration Management Program at TELUS Health allows for coordination of claims with the Saskatchewan and
Manitoba Pharmacare Programs. This program ensures that insurance carriers are not paying for claims which should be covered
under the provincial plan.
Cardholders have already been instructed by their carriers to register for the provincial plan. Cardholders who have already
registered with Pharmacare programs must advise their insurance carrier that they have registered. Each carrier will determine
dollar value thresholds they will use for senior and non-senior cardholders. Only drugs eligible under Pharmacare Programs will be
tracked towards the thresholds.
When a claim is submitted for cardholders of these plans who have not registered, a message is sent advising: REGISTER WITH
PROVINCIAL PLAN. Please note that the threshold is not based on time, but dollar value. Therefore, upon receiving this message,
there is no deadline issue involved.
However, if the cardholder is nearing the dollar threshold, the message will be: FAILURE TO ENROL MAY SUSPEND PAYMENT.
Once a cardholder has reached the dollar threshold, claims will reject and the message will be INSURER REQUIRES PROV PLAN
ENROLMENT.
To ensure proper payment, it is important that the above messages are relayed to the cardholder so they are aware of the need to
register with the Pharmacare programs.
Information on registering with the Pharmacare programs is on these government websites:
Saskatchewan - http://www.health.gov.sk.ca/ps_drug_plan_special.html
Manitoba - http://www.gov.mb.ca/health/pharmacare/index.html
Contact the TELUS Health Assure Claims Pharmacy Support Centre should you require further assistance.
Specialty Drug Program (SDP)
TELUS Health is introducing a new Speciality Drug Program (SDP) which will allow plan sponsors to coordinate benefits with
Provincial Drug Programs other than the Senior’s Pharmacare plan.
When a claim is submitted to TELUS Health for a drug on the Speciality Drug Program, and the plan sponsor has opted into the
program, the claim will reject with a 2060 code: Speciality drug authorization required. A plan sponsor may choose to offer First
Time Forgiveness for a drug claim on their Speciality Drug Program. This allows for payment of a claim while cardholders begin the
process of requesting provincial coverage. In this case, when the claim is adjudicated by TELUS Health, payment will be returned
with a 6024 code: Apply to province or payment may be suspended. Please communicate this message to patients in order to
avoid any disruption in coverage.
If patients do not apply for coverage with the Province, or a plan sponsor does not offer First Time Forgiveness, subsequent claims
will be rejected. Please note: there is no intervention code which can be submitted by the Pharmacy to bypass the Speciality Drug
Program.
Pharmacies should advise patients to contact their plan administrator for additional details.
Pharmacy Manual 39
Section 8
Drug Plan Types
Pharmacy Manual 40
Section 8
Drug Plan Types
Coverage
TELUS Health administers many diverse types of drug plans. These plans range from comprehensive, with coverage of many
“prescription-by-law” drugs and OTC drugs, to more restricted managed care plans that may be based on a “frozen” benefit list as
of a specific date, or based on a provincial formulary. TELUS Health also administers plans on behalf of WSBC in British Columbia
and WSIB in Ontario.
Our Comprehensive Plans generally allow:
Prescribed medications bearing a valid Drug Identification Number (DIN) and listed as prescription requiring in Federal or
NAPRA drug schedules.
Selected injectable drugs, injectable vitamins, insulin, and allergy extracts bearing a valid DIN.
Extemporaneous preparations or compounds where one of the ingredients is an eligible benefit and no component is
considered to be cosmetic in nature.
Disposable needles/syringes for administration of insulin (including disposable needles only, for non-disposable insulin
delivery devices), lancets and chemical reagent testing materials used for monitoring diabetes.
If a plan includes over the counter DINs, the following classes may be eligible:
acne preparations antiseptics pediculocides
analgesics cough and cold preparations potassium replacements
antacids diarrhoea preparations scabicides
antifungals iron supplements single entity calcium salts
antihistamines laxatives single entity fluorides
antimalarials mucolytic agents topical emollients
antinauseants muscle relaxants
antipsoriatics nitroglycerin
If a plan is “prescription-by-law”, the following over the counter products may be eligible benefits:
nitroglycerin
potassium replacements
selected single entity fluorides
selected iron supplements
Pharmacy Manual 41
Natural health products and TELUS Health drug plans
Health Canada introduced legislation to regulate natural health products on January 1, 2004. Under this legislation, natural health
products are defined as the following: vitamins and minerals, herbal remedies, homeopathic medicines, traditional medicines,
probiotics, and other products like amino acids and essential fatty acids. These products would be issued a Natural Product
Number (NPN) or a Homeopathic Medicine Number (DIN-HM).
Natural health products that had previously been issued a drug identification number (DIN) were given a six-year period, from
January 1, 2004 to December 31, 2009, to transition to an NPN or DIN-HM. All natural health products must comply with all the
Regulations by January 1, 2010.
Effective January 1, 2010, all DIN products changing status to natural health products will be removed from coverage under
TELUS Health’ drug plans. In addition, products may continue to be removed from coverage after January 1, 2010 as new
information becomes available from Health Canada. Examples include, but are not limited to, the following: iron supplements,
potassium and magnesium.
Please note that there may be some cases where a plan sponsor may continue to include these natural health products as
covered drug plan benefits.
Generic plans
If a plan has a generic rider, then the adjudicated ingredient cost will be based on the lowest priced interchangeable product
recognized in the province where the prescription is dispensed, plus a professional fee.
Prescriptions ordered as “No Substitution” by the authorized prescriber , are eligible for payment above the cost of the lowest
priced interchangeable product, when the claim is flagged as “N” for “No Substitution” or Product Selection = “1” (Prescriber’s
Choice) for CPhA3 EDI claims. Please note that certain groups may have a mandatory generic substitution plan where the lowest
cost interchangeable product will still be paid even if “No Substitution” is ordered by the authorized prescriber.
Frozen formularies
A frozen formulary is a plan that does not automatically allow for the inclusion of new products. The benefit list will remain constant
as of a specific date. Any new product introduced after this date will be evaluated on an individual basis for inclusion to the plan.
The TELUS Health Assure Claims National Formulary
The TELUS Health Assure Claims National Formulary has been created to serve the needs of the working population.
The TELUS Health National Formulary Committee manages this formulary with consultation from ReVue, an external, independent
group of healthcare experts. In managing the TELUS Health Assure Claims National Formulary, various references are considered
including medical and clinical research, standards of therapy, and clinical practice guidelines.
Pharmacy Manual 42
Exclusions
Most TELUS Health plans exclude the following categories of products.
Atomisers, appliances, prosthetic devices, colostomy supplies, first aid kits or equipment, electronic diagnostic monitoring
or testing equipment (such as “Glucometer®”), non-disposable insulin delivery devices (such as “Novolin Pen®”), delivery or
extension or spacer devices for inhaled medications (such as “Diskhaler®”, “Aerochamber®”), spring loaded devices used to
hold lancets, alcohol, alcohol swabs, disinfectants, cotton, bandages, or supplies and accessories for the aforementioned.
Oral vitamins, minerals, dietary supplements, infant formulas, or injectable total parenteral nutrition (TPN) solutions, whether or
not such a prescription is given for a medical reason, except where Federal or Provincial law requires a prescription for their sale.
Diaphragms, condoms, contraceptive jellies/foams/sponges/suppositories, intrauterine devices (IUDs), contraceptive implants,
or appliances normally used for contraception whether or not such a prescription is given for a medical reason.
Homeopathic and Herbal preparations.
Prescriptions dispensed by a physician, dentist or in a clinic or in any non-accredited hospital Pharmacy, or for treatment as
an inpatient or outpatient in a hospital, including emergency status and investigational status drugs, unless otherwise approved
by the insurance carrier.
Preventative immunization vaccines and toxoids.
Allergy extracts, compounded in a lab, and not bearing a unique DIN number.
Products bearing a valid Natural Product Number (NPN) issued by Health Canada
Items deemed cosmetic (even if a prescription is legally required or prescribed for a medical reason), such as topical minoxidil,
topical preparations considered cosmetic in nature (Neostrata products, de-pigmenting agents), or sunscreens.
Any medication that the person is eligible to receive under the applicable Provincial Drug Benefit Plans.
Dispensing limitations
Most plans allow a maximum of a 34-day supply for non-maintenance medications, and 100-day supply for maintenance
medications if so ordered by the authorized prescriber.
Any request for quantities greater than a 100-day supply, the cardholder should contact their Benefits Department, otherwise the
cardholder will be required to pay out of pocket for the excess supply and submit the receipt manually for reimbursement.
Maintenance classification is assigned on a per DIN basis and includes most of the drugs in the following classes:
antiasthmatics
antiparkinson
antihypoglycemic agents
antibiotics for acne
antidepressants
transdermal or oral contraceptives
anticoagulants
cardiac agents
potassium replacements
anticonvulsants
female hormone replacement
thyroid agents
Where appropriate, please dispense a 100-day supply of these medications, with only one dispensing fee charged per 3 months.
This is an excellent example of how pharmacies can work with TELUS Health to provide cost-efficient, quality pharmaceutical care.
Note: In BC, WSBC follows the BC Pharmacare guidelines for days supply.
Pharmacy Manual 43
Dispensing Fee Limits
On April 1, 2014 TELUS Health will begin offering a new option to plan sponsors to help manage their drug plan costs.
A plan sponsor currently can limit the fee by setting a fee cap, or may have the fee as a deductible. The new option will limit the
number of dispensing fees reimbursed in a defined period of time (e.g. monthly, annually). A plan sponsor can customize this
option by deciding on the dispensing fee limits and which drugs or drug classes the limits impact.
When a dispensing fee limit is reached, the pharmacy will receive the following return code 6034: EXCEEDS MAX # OF DISP
FEES FOR THIS DRUG. After the maximum number of fees is reached, the pharmacy may charge the plan member their usual
and customary dispensing fee.
Plan members will be advised in advance from their insurance company if dispensing fee limits apply to their plan design.
Maximum Allowable Cost Pricing (MAC) or Reference Based Pricing (RBP)
A number of plan sponsors offer managed care plans that specify the maximum amount reimbursed on a claim. This is called
Maximum Allowance Cost (MAC) pricing or Reference Based Pricing (RBP). MAC pricing or RBP means the drug price considered
by the plan is based on the price of a different product, within the same therapeutic category. The reference drug can be selected
in a variety of ways, but ultimately the insurance carrier and/or the plan sponsor decides. The reference drug is not always the
generic, or the cheapest drug. Often times it is the drug that is used most frequently in the affected group or province. Insurers can
use this program in one DIN class or in multiple DIN classes. The reference drug is always in the same category as the drug being
adjudicated.
The return code 6012 – “cross select pricing” (CPH3 code DK) -- means the drug being adjudicated is part of this type of plan.
The pharmacist is not expected to consult the physician to switch the drug to a lower costing one. The cardholder and the
physician are free to choose any drug in the therapeutic category; however, it will only be reimbursed at the reference drug price.
The cardholder is responsible to pay the difference in cost between the drug dispensed and the reimbursed amount.
The TELUS Health Maximum Allowable Cost (MAC) Program
Effective January 1, 2013, a number of groups will be launching the TELUS Health Maximum Allowable Cost (MAC) program.
Maximum Allowable Cost is the maximum reimbursable amount for specific drugs within the same therapeutic class. Details of
the program have been sent to affected plan members. Depending on the drug category, a few drugs may be available below the
price of the reference drug and not subject to a cutback.
When a drug claim subject to the MAC pricing program is submitted, the plan member will be reimbursed only up to the price of
the reference drug chosen for that class. The value returned after claim adjudication will show how much is to be collected from
the patient, and will depend on the price difference between the chosen DIN and the reference drug.
Plan members opting to use more expensive alternatives will be required to pay the difference between the drug dispensed and
the reimbursement amount.
Pharmacy Manual 44
Drug classes and drugs included in the MAC Program* (as of December 2012)
Drug Class Specific drugs (including generics) Drugs within MAC
above MAC
Angiotensin converting enzyme Mavik (Trandolapril) Altace (Ramipril)
inhibitors Accupril (Quinapril) Zestril, Prinivil (Lisinopril)
Coversyl (Perindopril)
Monopril (Fosinopril)
Vasotec (Enalapril)
Inhibace (Cilazapril)
Lotensin (Benazepril)
Angiotensin II receptor blockers Cozaar (Losartan) Diovan (Valsartan)
Olmetec (Olemesartan) Atacand (Candesartan)
Teveten (Eprosartan) Micardis (Telmisartan)
Avapro (Irbesartan)
Edarbi (Azilsartan)
Dihydropyridine calcium channel Plendil, Renedil (Felodipine) Norvasc (Amlodipine)
blockers Adalat XL (Nifedipine)
HMG-CoA reductase inhibitors Lipitor (Atorvastatin) Crestor (Rosuvastatin)
Zocor (Simvastatin)
Mevacor (Lovastatin)
Pravachol (Pravastatin)
Lescol (Fluvastatin)
Proton pump inhibitors Pantoloc (Pantoprazole sodium) Pariet (Rabeprazole)
Pariet (Rabeprazole)
Dexilant (Dexlansoprazole)
Prevacid (Lansoprazole)
Losec (Omeprazole)
Tecta (Pantoprazole magnesium)
*The reference drug/price is subject to change.
When you submit a drug claim that is subject to the MAC pricing program, you may receive one or both of the following return
codes and translated messages, depending on your software:
Return Codes from MAC Pricing Program
Message 1 Message 2
CPhA3 Code QR: Maximum Allowable Cost (MAC) paid E9: Reduced to reference-based price
TELUS Code 6028: Maximum Allowable Cost paid 6029: Reduced to price for DIN 12345678*
*Multiple generics from various manufacturers may be eligible at the same reference price. Due to messaging limitations, the DIN
returned is just one example of many eligible products.
The value returned on the claim will show how much is to be collected from the patient.
The cardholder and the physician are free to choose any drug in the therapeutic category; however, it will only be reimbursed
at the reference drug price. The cardholder is responsible to pay the difference in cost between the drug dispensed and the
reimbursed amount.
Pharmacy Manual 45
New Drug Plan Coverage Based on Drug Price
TELUS Health has introduced new coverage options for plan design and reimbursement. In addition to the standard plans that
offer coverage at specific percentage levels and/or fixed dollar deductible amounts, certain plans will now provide the option of
reimbursing specific DINs at a customized price.
Unlike a standard price cutback, which is based on our standard TELUS Health price file and cannot be passed on to the patient,
this customized price is considered the amount reimbursed by the plan. Similar to a plan that covers 80%, with the patient paying
the remaining 20%, the customized price of the DIN is considered the coverage amount, and the patient must pay the price
difference. The following return codes are associated with these claims.
Message
CPhA3 Code FG: Drug cost paid as per provider agreement
TELUS Code 6030: Drug cost paid as per provider agreement
The customized price may be based on a Generic Price, a Maximum Allowable Cost program, or may simply be a fixed
percentage of the price of a particular drug.
For example, a plan that previously provided 90% coverage may also cover specific drugs based on a customized price
(as determined by the plan sponsor) of 70%:
A claim for Dispensing Fee = $8 and DIN cost = $100
The DIN Cost Eligible will be reduced to $70 (as chosen by the plan sponsor)
The Claim will be paid at Dispensing Fee = $7.20 and DIN Cost $63 (90% of $70)
The patient will be responsible for $37.80
Pharmacy Manual 46
Section 9
The Trial, Maintenance and
Prior Authorization Programs
Pharmacy Manual 47
Section 9 -
The Trial, Maintenance
and Prior Authorization Programs
The TELUS Health Trial, Maintenance and Prior Authorization Programs are available options for employers to select for their drug
plans. As a result, only certain cardholders will be subject to these programs. These programs can be used independently or in
combination.
Trial Drug Program
The Trial Program is a voluntary program designed to promote the dispensing of smaller quantities of prescription drugs that have
a high incidence of side effects, and are a new treatment for the cardholder. This prevents waste if the medication is not tolerated.
Procedure for Trial Program:
1. For drugs eligible under the Trial Program, you will receive the message “INVALID DAYS SUPPLY – TRIAL DRUG PROGRAM.”
2. Ask the cardholder if they would like to participate in the Trial Program. If the cardholder refuses, use the override code UG.
If the cardholder accepts, you can resubmit a 7-day supply of the medication.
3. Contact the cardholder after 5 or 6 days to determine if the drug is effective and tolerated.
4. If the drug is tolerated, the balance of the prescription can be filled and the pharmacy is eligible to receive a second
dispensing fee.
5. If the drug is not tolerated, you may choose to contact the prescribing physician to request an alternative therapy.
6. You can submit a claim for the alternative therapy, which may also be subject to the Trial Program.
7. If no alternative therapy is prescribed after consultation with the prescribing physician, you may be eligible to receive
an $8.00 cognitive fee. The cognitive fee can be billed to TELUS Health using PIN number 19000001.
Examples of drug classes included in telus’ Trial Program:
Angiotensin-Converting Enzyme (ACE) Inhibitors
Angiotensin II Receptor Blockers
Beta Blockers
Calcium Channel Blockers
Lipid Lowering Agents
Proton Pump Inhibitors
Pharmacy Manual 48
Maintenance Program
The Maintenance Program is a voluntary program designed to encourage the dispensing of a larger days supply to cardholders
who are taking a medication for a long duration.
Procedure for Maintenance Program (for drugs considered maintenance by TELUS Health):
For cardholders on this program, claims for drugs considered by TELUS Health to be Maintenance drugs will get the warning
message “DRUG ELIGIBLE FOR 100 DAY MAINT QUANTITY.” This is to encourage cardholders to get a larger drug supply for
medication intended for treatment of a chronic condition. You may need to contact the physician for authorization to dispense a
100-day supply of the medication.
Procedure for Maintenance Program (for drugs considered acute by TELUS Health):
1. For drugs eligible under the Maintenance Program, you will receive the message “RESUBMIT ONE MONTH SUPPLY.”
2. Ask the cardholder if they would like to participate in the Maintenance Program. If the cardholder refuses, use the override
code UG to opt out of the program. This will allow the claim to be processed; however, since the cardholder has opted out of
the program the claim is still subject to any days supply limitations (e.g., 34 days) set by the employer.
3. If the cardholder accepts, you must adjust the drug quantity and days supply and resubmit the claim with a 30-day supply.
4. After three consecutive one-month prescriptions, the cardholder will be eligible to receive a three-month supply. When filling
the third one-month supply, you will be prompted with the message “SUBMIT 3 MONTHS NEXT.”
5. The rejection message “RESUBMIT 3 MONTH SUPPLY” will appear when you fill the fourth prescription for a 30-day supply.
6. You may need to contact the doctor to increase the days supply. Upon receiving approval from the physician, adjust the
drug quantity and days supply and resubmit the claim for three months. The pharmacy may be eligible to receive an
$8.00 cognitive fee. The cognitive fee can be billed to TELUS Health using PIN number 00999072.
Trial and Maintenance Programs combined
Procedure for Combined Trial and Maintenance Programs:
1. The Trial Program takes precedence over the Maintenance Program.
2. Follow the steps as described in the Trial Program.
3. When you submit the balance of the prescription, the days supply cannot exceed 34 days. Caution: If a claim with a days
supply greater than 34 days is submitted, the drug cost will be cut back to the cost of a 34-day supply, and the system will
return a message notifying you of the adjustment.
4. The balance of the original prescription will be included in the Maintenance Program steps.
5. Follow the steps for the Maintenance Program.
TELUS Health may add or remove drugs from the program or change the clinical protocols when deemed necessary.
If for any reason the cardholder chooses not to participate in these voluntary programs, or if you feel it is appropriate
to override the programs, the following codes may be used:
UG Consulted patient – dispensed as written
MG Override – various reasons
MV Override – vacation supply (still subject to rules surrounding Vacation Supplies, see section 5)
For audit purposes, TELUS Health requires that the pharmacy document all relevant details about the prescription to support the
selection of overrides and the submission of claims for cognitive fees.
Pharmacy Manual 49
Prior Authorization Program
The Prior Authorization Program is designed to target high volume and/or expensive medications that are not necessarily first-line
therapies or may be used for non-approved indications. Individuals will be reimbursed for the drug only if they meet the medical
criteria as defined by clinical guidelines. These guidelines are similar to those established by Provincial Formularies as well as
Health Canada approved information on the product monograph of the medications. Cardholders have the option of paying for the
medication if they do not want to delay starting therapy. Note that if the plan sponsor selects the Prior Authorization Program, you
cannot override the reject at the pharmacy.
For a list of current medications on the Prior Authorization Program, refer to the following link:
http://www.telushealth.com/health-solutions/claims-and-benefits-management/drug-claims/prior-authorization-program/forms
Procedure for prior authorization program:
1. For cardholders on this program, a claim for a targeted drug will be declined with the message “PRIOR AUTH REQUIRED.”
Please note that if a claim is rejected with the messages “DIN NOT COVERED”, “DIN/PIN NOT A BENEFIT”, “CARRIER AUTH
REQUIRED” or “CRDHLDR TO CONTACT INSURER FOR AUTH FORM” at the end of the message sentence, then the
cardholder is not eligible for Prior Authorization and this program does not apply.
2. The cardholder is required to obtain the appropriate Prior Authorization Program request form from either their employer or
their insurer’s website.
3. The form must be completed by cardholder and the patient’s physician and faxed to TELUS Health Pharmacy
Services department at 1 866 840-1509 or by mail to TELUS Health, 4141 Dixie Road. PO Box 41154,
Mississauga, ON. L4W 5C9. A complete request must include signature of the patient (or parent/legal guardian) and the
physician before it is processed.
4. Upon receiving the form containing all the required information, the request will be evaluated within two to five business days.
Pharmacy Services will then contact the cardholder, or the pharmacy as indicated on the form, with the result.
5. Once the request is approved, further Prior Authorization application is seldom needed, unless required by the patient’s drug
plan. In some cases, payments are subject to annual limitations or total dollar maximums.
Please note: The pharmacy name and phone number are optional information the cardholder can supply to us on the
Prior Authorization Program’s reimbursement request form. This information allows TELUS Health to contact the cardholder’s
pharmacy with the result of the request. The pharmacy may opt to discuss alternative therapies with the cardholder if the
request is declined, or to contact them to collect their approved prescription.
TELUS Health or the insurer may add or delete drugs from the Prior Authorization Program or change the clinical criteria when
deemed necessary.
Pharmacy Manual 50
Section 10
e-Sampling Program
Pharmacy Manual 51
Section 10
e-Sampling Program
TELUS Health, in collaboration with participating pharmaceutical manufactures, offers an e-sampling program, which allows
pharmacies to provide medication samples to your patients at no charge. This replaces the physical samples pharmaceutical
manufactures would leave with physicians, and has the added benefit of including the pharmacist in the sampling process.
Patients will receive a pre-printed Sampling coupon from their physician. When the coupon is accompanied by a prescription from
an authorized prescriber, the patient can redeem the coupon for the specified medication, dosage and quantity at the pharmacy of
their choice. The cost of the medication and the dispensing fee are billed directly to TELUS Health, and the patient is not required
to pay for the sample medication.
Every e-Sampling coupon will look slightly different; however, the TELUS Health Assure logo will appear on all coupons. Each
coupon contains drug card billing information in the same format as the TELUS Assure Claims Card. The claim processing for
a Sampling coupon works in the same manner as a regular prescription. The claim information is transmitted for adjudication to
TELUS Health and the pharmacist receives the real time adjudication result. Following submission of the Sample claim, please
remove the Sample coupon billing information from the patient’s profile to prevent an unnecessary reject in the future. The
pharmacies will receive payment in the same way as the existing payment setup with TELUS Health.
The coupon presented by the patient can only be used for that specific patient and is not transferable. Each coupon can only be
used once and only one coupon is to be processed per patient. The specified medication, dosage and quantity claimed must
match the physician’s prescription and cannot exceed any maximum specified on the coupon. Changes to the medication or
strength are not permitted. The quantity dispensed may be less than the quantity on the Sampling coupon; however, the balance
cannot be billed later. Please attach the coupon to your computer generated “hardcopy” and retain in your files for audit purposes.
Pharmacy Manual 52
Section 11
PSHCP
Pharmacy Manual 53
Section 11
PSHCP
TELUS Health is the Pharmacy Benefits Manager for the Public Service Health Care Plan (PSHCP). The PSHCP has implemented
a pay-direct drug program for all PSHCP members and their eligible dependants. Pharmacies can now submit drug claims and
some medical supply claims electronically on behalf of PSHCP plan members.
Contact us:
Tel.: 1 800 668-1608
Fax: 1 866 840-1466
Monday - Sunday: 5:30 a.m. to 2 a.m. ET
When contacting the Pharmacy Support Centre, please have your special PSHCP 10-digit provider number available.
These phone lines are for pharmacies ONLY. Please DO NOT give cardholders the Pharmacy Support Centre telephone
number. If cardholders have any questions or concerns, they should contact their Benefits Department or Plan Administrator
at their place of employment.
More helpful information can be found on our website at:
http://www.telushealth.com/health-solutions/claims-and-benefits-management/pshcp-provider-information
Members of the PSHCP will have a Carrier Code of 12 on their pay-direct drug cards. Examples of the cards can be found on
our website, under ‘PSHCP Information’.
Handy references pertaining to medical supplies are also available on our website.
PSHCP medical supplies pseudo DIN list:
http://www.telushealth.com/health-solutions/claims-and-benefits-management/pshcp-provider-information/supplies-list
PSHCP diabetic supplies pseudo DIN list:
http://www.telushealth.com/docs/assure-claims/diabetic-pseudo-din-list.pdf
TELUS Health is the pharmacy benefits manager for PSHCP. The same pharmacy policies and procedures for regular
TELUS Health claims apply to all PSHCP claims submitted to TELUS Health. Please inform the plan member there is a limited day
supply allowed for online adjudication. Plan members are required to discuss with their plan administrator for additional day supply,
i.e. vacation supply, etc.
Pharmacy Manual 54
Appendix 1
Request for change in provider profile
Whenever a pharmacy makes a change in any of the categories listed below, the designated pharmacy manager must inform
TELUS Health so we can update your provider profile. Please follow the instructions on how to notify us.
Types of pharmacy change:
Change in pharmacy contact information such as address, phone number, fax number, or email address (see Instruction A)
Change in dispensing fee (see Instruction A)
Change in payment option (see Instruction A)
Change in bank account (see Instruction A)
Change in designated pharmacy manager only (see Instruction B)
Change in legal name (see Instruction C)
Change in ownership (see Instruction C)
You can now complete a simple change request form to notify us. This is for all changes except a change in designated pharmacy
manager, change in legal name, or a change in ownership.
Instruction A : Please complete the Pharmacy Provider Change Request Form included in this Appendix and send it to Provider
Services. The form can also be accessed online at http://www.telushealth.com/Solutions-for-pharmacists/download-drug-
claims-documents. Just click on the Pharmacy Provider Change Request Form in the Pharmacy Support Tools section. You can
also call the TELUS Health Assure Claims Pharmacy Support Centre at 1 800 668-1608 to request a form to be faxed to you.
Instruction B : For the change in designated pharmacy manager only and no other changes, please complete Pages 1 and 2 of
the Pharmacy Provider Agreement and fax it to1 866 840-1466.
Instruction C : For the change in legal name or change in pharmacy ownership, please contact the TELUS Health Assure Claims
Pharmacy Support Centre to request a new Pharmacy Provider Agreement. TELUS Health will issue a new provider number to you
upon receipt of the signed new agreement.
Why is it important to inform us about any changes?
Your pharmacy provider number is directly linked to your provider profile. In order to ensure you are paid properly and according to
the payment instruction, you have given us, you must provide us with the most current information. A change in any of the above
categories may affect you financially.
If the pharmacy profile change includes a change of bank account, please verify that the proper payment has gone into your new
account the day after the effective date of your account change. If there are any discrepancies, please contact the TELUS Health
Assure Claims Pharmacy Support Centre immediately.
Pharmacy Manual 55
PART A — Providers Current Information (MUST BE filled out)
Legal Registered Name: Provider No:
Contact: Phone/Fax No:
Please indicate the type of change:
Change of Operating Name - complete “Part B” Change in Payment Option – complete “Part E”
Change of Address – complete “Part C” Change in Banking Information – complete “Part F”
Change in Dispensing Fee – complete “Part D”
PART B — Change of Operating Name
PART C — Address Change
New Address: Effective Date:
City, Province: Postal Code:
Phone/Fax No: E-mail Address:
PART D — Dispensing Fee Change
Present U & C Fee: Effective Date:
New Fee:
PART E — Payment Option Change
Present Payment Option: Effective Date:
New Payment Option:
PART F — Bank Change (if completing this section, please fax or mail. For your security, DO NOT send by email)
Bank Name: Bank No:
Account No: Transit No:
Note: If the cheque is not pre-printed with your name (either legal or operating name or both) then a letter from the bank, signed by an
officer of the bank, identifying the name of the account, confirming the account number and the names of the signing officers is required.
If you are changing your bank account, we strongly recommend that you verify all payments have gone into the correct account the day
after the bank account change.
Please note: We require the Designated Pharmacy Manager to sign the form. If there has been a change of pharmacy manager since
signing the agreement with Emergis Inc., then we require a Change of Manager form to be filled out.
Authorized Signature of Pharmacy Manager Print Name Effective Date
* If this is a change of Legal name you will need to fill out
a new agreement and receive a new provider number
Pharmacy Provider Change Request
We require TWO weeks advanced notice for any changes to your profile to ensure changes will be done on time.
Send completed form to:
TELUS Health Inc.
5090 Explorer Drive, Suite 1000, Mississauga, ON
L4W 4X6
or FAX it to: 1 866 840-1466
Need help? Please call 1 800 668-1608
Pharmacy Manual 56
Appendix 2
Diabetic Pseudo-din List
An updated list can be accessed online at:
http://www.telushealth.com/Solutions-for-pharmacists/download-drug-claims-documents
Pharmacy Manual 57
Appendix 3
Glossary of terms
Actual Acquisition Cost (AAC) The real cost paid to obtain a drug. This may be the purchase price direct from the
manufacturer or from a recognized pharmaceutical wholesaler.
Adjudication Processing a claim through a series of edits that determine appropriate payment.
Authorized Prescriber An authorized prescriber is a physician, surgeon, dentist, or other healthcare professional
prescriber in good standing with their governing body, where provincial laws permit these
persons to prescribe. Any provincial restrictions placed on the prescribing practices of
the above listed professions are followed by TELUS Health (e.g. a specific list
of drugs that a practitioner can prescribe from)
Cardholder Exception The plan sponsor has instructed the insurance carrier to allow coverage of one drug or
a group of drugs for a specific cardholder. Other family members and employees at that
company are not eligible unless they too have had an exception authorized.
Carrier Insurance company insuring the plan or providing administration services.
Co-Insurance A percentage (e.g. 10% or 20%) of the cost of the drug or prescription that must be paid
on each item every time a prescription is dispensed.
Co-Pay A set dollar amount applied to each individual prescription dispensed (e.g. $2.00 or
$5.00 per prescription).
CPhA3 The standard established by the Canadian Pharmacists Association for electronic
exchange of claim information.
Deductible A set dollar amount that must be paid by the cardholder and/or dependant’s before
coverage of health benefits can begin. Deductibles are normally reset annually. (e.g.
$10.00/$50. 00), and do not necessarily coincide with a new calendar year.
Dependent Coverage The employee has insurance that would include coverage for a spouse and/or
eligible children.
Dispensing Fee Cap The plan sponsor may opt to pay only a fixed dollar value towards the dispensing fee.
This may be set at various levels, depending on the plan.
Drug Utilization Review (DUR) Most pharmacies utilize software programs that identify levels of potential drug
interactions. TELUS Health DUR check goes one-step further, in that the check
is run against all claims for the cardholder processed through the TELUS Assure Claims
Card. TELUS Health then alerts the pharmacy staff of potential interactions
with drugs dispensed in any other pharmacy.
Electronic Data Interchange The transfer of data between the pharmacy and TELUS Health using networks,
(EDI) and/or the Internet. EDI is increasingly important as an easy mechanism for secure
exchange of confidential information.
Electronic Funds Transfer The paperless transfer of money from one bank account to another.
Electronic Reimbursement Online verification of coverage and eligibility resulting in claim settlement in real time.
TELUS Health Assure This is TELUS Health own managed care plan. It is not necessarily related to
Claims National Formulary any specific drug plan.
Formulary A specific list of eligible drugs. Formularies may mimic provincial formularies, and be
updated to reflect provincial changes. A formulary may also be created at the request of
an employer and maintained on their behalf.
Issue Number This two-digit number (usually 01) acts as a control if a card is lost or stolen. It is
essential to make sure that the most current issue number is recorded.
Pharmacy Manual 58
Lowest Cost Alternative The lowest unit cost established for a drug within a set of inter-changeable generics.
A plan with a generic rider will reimburse the pharmacist to the level of the lowest cost
generic.
Maximum Allowable Cost (MAC) The drug price paid by the plan is based on a different product within the same
therapeutic category. See also RBP (Reference Based Pricing).
Maintenance and Maintenance drugs are those that are used long term, e.g. thyroid drugs, blood pressure
Non-Maintenance Drug drugs. Non-maintenance or acute drugs are those taken for a shorter period of time,
e.g. antibiotics and cough suppressants.
Maintenance Program A voluntary program designed to encourage the dispensing of a larger days supply to
cardholders who are taking maintenance or acute medication for a long duration and
have been established on the therapy.
Pharmacy Benefit Manager A company (such as TELUS Health) that adjudicates online prescription claims
(PBM) from registered pharmacies where a signed Provider Agreement exists.
Plan Sponsor The employer or organization that pays for the insurance.
Policy Year The anniversary of the date when the coverage came into effect. This may determine
when the annual deductible is reset; however, on some plans deductibles are managed
on a calendar year basis.
Preferred Provider Network Employers may decide to have their members’ prescriptions filled from certain
(PPN) or Preferred Provider pharmacies or chains of pharmacies. These pharmacies have agreed to provide
Option (PPO) additional control services on prescribed drugs at the point of sale.
Primary Cardholder Person for which the benefits have been setup. Usually the employee or member of
the Plan Sponsor.
Settlement Period The payment schedule determined by the pharmacy. Options include next day electronic
fund transfer, twice monthly or every thirty days.
Sliding Co-Pay Employers will pay a percentage of the first “x” dollars spent and then a different
percentage of all claims above that limit.
Trial Program A Voluntary program designed to promote the dispensing of smaller quantities of
prescription drugs that have a high incidence of side effects, when the cardholder has
not used the medication previously.
Unlisted Compound Code The number supplied by the software company to indicate whether the extemporaneous
compound is a cream, ointment, liquid for internal use, etc.
Pharmacy Manual 59
Appendix 4
Common reasons for rejection
1. DIN not covered
This reject message indicates that the DIN/PIN is not a benefit under the plan. The cardholder must pay cash for the prescription
or contact their physician to see if an alternative could be prescribed.
2. Card not effective
When this message appears, it indicates that the card is not currently active. The cardholder must contact their plan administrator
to correct the problem. The cardholder must pay for the prescription.
3. Card terminated
When this message appears, it indicates that coverage has been cancelled active. The cardholder must contact their plan
administrator to correct the problem. The cardholder must pay for the prescription.
4. Cardholder has single coverage only
This indicates that the cardholder has not registered any dependants under their benefits plan. The cardholder must contact their
plan administrator to correct the problem. The cardholder must pay for the prescription.
5. Overage dependent not registered
Once a dependant reaches the maximum age (18, 19, or 21 for example) they must register as an overage dependent.
The cardholder must contact their plan administrator to correct the problem. The cardholder must pay for the prescription.
6. Cardholder information is incorrect (usually DOB difference)
Please verify that the correct relationship code and date of birth have been entered for the cardholder. If you are still having
difficulties, please see Incorrect Date of Birth, Section 4, Page 16 or contact the Pharmacy Support Centre for further assistance.
7. Prior Auth required
If you receive this reject message, the cardholder is required to obtain the appropriate Prior Authorization Program request form
from either their employer or their insurer’s website. The Cardholder and their physician must complete the form. Once approved
Pharmacy Services will then contact you or the cardholder, as indicated on the form, with the result. In addition, once the claim
is approved, further Prior Authorization application is not required, unless prompted by our system. In some cases, payments are
subject to annual limitations or total dollar maximums.
8. Carrier auth required
If you receive this reject message or “CRDHLDR TO CONTACT INSURER FOR AUTH FORM” then the cardholder is not eligible
for Prior Authorization. The Cardholder must contact their plan administrator directly to obtain approval for coverage of the drug in
question.
Pharmacy Manual 60
Appendix 5
PINS for common compounds
NOTE: Use of these PINs will determine eligibility only. If any ineligible bases, ingredients or formats are used in the compound,
it can be still deemed ineligible during review.
Drug/Chemical/Main Ingredient
Methadone
British Columbia
Alberta
Saskatchewan
Manitoba
Ontario
Quebec
New Brunswick
Nova Scotia
Newfoundland
Prince Edward Island
NIHB (COB Claims only)
Methadone capsules
British Columbia
(for Pain Management)
progesterone suppositories
progesterone topical compounds
Remicade®
testosterone topical compounds
topical estrogen(s) compounds
(containing estriol/estrone/estradiol)
Topical Non-Steroidal Anti-
Inflammatory Drugs (NSAIDs)
diclofenac topical
ibuprofen topical
indomethacin topical
ketoprofen topical
naproxen topical
PIN/DIN to be used
Varies by province
(see below)
66999997
66999998
66999999
67000000
N/A
00990043
N/A
N/A
00907561
00999734
N/A
00908835
00990103
N/A
00990054
90800233
Product DIN
90800234
00990111
00999984
Notes
Submit without using an unlisted compound code, cost
should include all compounding charges (fee submitted
separately).
Methadose™ 10mg/ml intervention
Methadose™ 10mg/ml no intervention
Methadose™ 10mg/ml intervention
Methadose™ 10mg/ml no intervention
Methadone compounds no longer eligible in Alberta as of
Sept 1, 2013
Methadone compounds no longer eligible in Manitoba as of
January 2015
Methadone compounds no longer eligible in Ontario as of
Sept 1, 2014
Methadone compounds no longer eligible in PEI as of
Feb 17th, 2014
Methadone pain suppositories
Use relevant DIN/PIN as of Mar 1, 2014
For all strengths. NOTE: excludes 100mg as it mimics
Endometrin®.
For all strengths.
Submit without an unlisted compound code, cost should
include compounding time.
For all strengths. NOTE: for testosterone, not covered if it
mimics Androgel® or Androderm®
For all strengths. NOTE: for diclofenac, not covered if it
mimics Pennsaid™ or Voltaren Emulgel™
Pharmacy Manual 61
A
AAC 37, 57
Actual Acquisition Cost 17, 57
Alberta 29, 37, 60
Audit 7, 20, 22, 29, 33, 34, 35, 48, 51
Authorization 7, 15, 19, 20, 21, 33, 35, 38, 46, 47, 48
49, 59
Authorized Prescriber 15, 19, 20, 21, 41, 42, 51, 57
B
Balance Billing 17
Balancing Transactions 16
C
Card Not Effective 59
Card Terminated 59
Cardholder Exception 57
Cardholder has Single Coverage Only 59
Cardholder Information is Incorrect 59
Carrier 6, 7, 9, 10, 15, 16, 17, 18, 22, 34, 35, 37, 38
42, 43, 49, 53, 57, 59
Carrier Auth Required 59
Carrier Number 9, 10
Carrier Identification 10
Certificate Number 9
Change in Bank Account 54
Change in Designated Pharmacy Manager 54
Change in Dispensing Fee 54
Change in Legal Name 54
Change in Ownership 54
Change in Payment Option 54
Change in Pharmacy Contact 54
Change in Provider 54
Charged to Cardholders…. 17, 18
Claim Too Old 16
Claim Void 16
Co-Insurance 10, 18, 57
Collect From Your Cardholder 17
Communicating with Cardholders 7
Compliance Packaging 22
Compound Codes 25
Compound Verification 29
Compounds 25, 26, 27, 28, 29, 40, 60
Co-Pay 6, 18, 19, 57, 58
CPhA3 11, 21, 37, 41, 44, 45, 57
Crdhldr to Contact Insurer for Auth Form 49, 59
Cross Select Pricing 43
D
Date of Birth 11, 15, 29, 59
Days Supply 19, 22, 31, 32, 42, 47, 48, 58
Deductible 6, 10, 11, 18, 19, 37, 45, 57, 58
Deferred Payment Plan 17, 19
Dependent 6, 9, 10, 11, 15, 19, 20, 22, 31, 37
41, 47, 57, 59
Diabetic 18, 23, 24, 53, 56
DIN Not Covered 49, 59
DIN/PIN Not a Benefit 49
Dispensing Fee Cap 18, 57
Dispensing Limitations 42
Documentation 16, 19, 20, 21, 22, 35
Drug Age 31
Drug Eligible for 100 Day Maint Quantity 48
Drug Gender 31
Drug Interaction(s) 31, 32
Drug Plan Types 39, 40
Drugs That May Have Restrictions See Suggested
See Monthly Maximums
DUR see Drug Utilization Review
Drug Utilization Review 11, 19, 22, 30, 31, 32, 57
E
EDI 6, 10, 11, 16, 18, 21, 41, 57
Electronic Funds Transfer 6, 57
Electronic Reimbursement 10, 57
Eligible Compounds 26, 27
TELUS Assure Claims Card 8, 9, 10, 15, 18, 19, 23, 51
TELUS Health Assure Claims 6, 7, 11, 12, 13, 15, 16, 17
21, 25, 26, 29, 32, 35, 38, 41, 54
National Formulary 41, 57
e-Sampling 17, 50, 51
F
Formulary 18, 23, 40, 41, 57
Fraud Tips 35
I
Identification Number 9, 10, 40, 41
Cardholder Identification Number 9
Incorrect Date of Birth 15, 59
Ineligible Bases 26, 60
Ineligible Compounds 25
Index
Pharmacy Manual 62
I (continued)
Ineligible Drugs 26
Insulin 40, 42
Invalid Days Supply – Trial Drug Program 47
Issue Number 9, 57
L
Lancet 40, 42
Limited Use 37
Lowest Cost Alternative 58
M
MAC 18, 29, 43, 44, 58
Maintenance 22, 31, 42, 46, 47, 48, 58
Manitoba 29, 38, 60
Manufacturer Decreases 18
Maximum Allowable Cost 18, 43, 44, 45, 58
Maximum Professional Fee 11
Fee Cap 11, 18, 57
Minimum/Maximum Dosage 32
N
Next Day Payment 17
Non-Maintenance Drug 58
O
Ontario 19, 29, 37, 40, 60
Ontario Drug Benefit 37
ODB 29, 37
Overage Dependent Not Registered 59
P
Paper Claims 6, 15
Payment 30 Days Transaction Date 17
Payment Options 17
PBM 58
Pharmacist Prescribing/Adaptation 20
Pharmacy Audits 35
Pharmacy Benefit Manager 31, 58
Pharmacy Payment Options 17
Next Day Payment 17
Twice a Month Payment 17
Pharmacy Support Centre 6, 7, 12, 13, 15, 16, 17, 22, 23
25, 26, 29, 32, 34, 38, 53, 54, 59
Plan Sponsor 7, 10, 11, 18, 19, 21, 38, 41, 43
45, 49, 57, 58
Policy Number 9
Pricing 17, 18, 19, 23, 43, 44, 58
Primary Cardholder 10, 11, 58
Prior Auth Required 49, 59
Prior Authorization 7, 46, 47, 49, 59
Provider Agreement 17, 45, 54, 58
Provincial Registration Management Program 38
R
RBP 18, 43, 58
Reference Based Pricing 18, 43, 58
Refill Too Soon/Too Late 31
Relationship Code 9, 11, 15, 59
Resubmit 3 Month Supply 48
S
Sample TELUS Assure Claims Card 9
Sampling Coupon 51
Saskatchewan 29, 38, 60
Settlement Period 58
Spoiled Prescription 23
Submit 3 Months Next 48
Monthly Maximums 20, 21, 24, 32
Syringe(s) 26, 28, 40
T
Testing Strips 24
Therapeutic Duplications 31
Twice a Month Payment 17
U
Unlisted Compound Code(s) 25, 58, 60
V
Vacation Supply 22, 48, 53
Verbal Prescriptions 20, 21
Verbal Refill Authorizations 20
W
WSBC 10, 19, 40, 42
WorkSafe BC 19
WSIB 10, 19, 40
Workplace Safety and Insurance Board 19
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