NLPDP Benefit Limitations

Subject to Revision

Last Updated:    July, 2003

This document contains a listing of all medication benefits covered under the Social Services Drug Program (Plan E) or the Senior Citizens Drug Subsidy Plan (Plan N) for which limitations on their coverage apply. The benefit limitation initiative was first discussed in the July 19, 1996 Bulletin #14 and subsequent bulletins have identified additional products for which limitations have been established. Pharmacies will continue to be notified by bulletin of new product limitations and this document will be updated as changes are made.

The initiative of benefit limitations is to assist in assuring that benefits are provided on the basis for which the coverage was intended. As stated in the previous bulletins, adherence to these limitations shall be assessed through post-audit procedures.

Please note that the following limitations apply to ALL benefit brands in the drug category specified.

Coverage of acetaminophen was intended to allow for the provision of the more expensive formulations designed for pediatric use. The program does not provide coverage for the inexpensive, regular strength and formulation (ie. 325mg tablet). Individuals for whom this dosage and form would be appropriate will be responsible for the cost. Thus, the acetaminophen forms that remain as benefits shall have age restrictions for coverage applied. The benefit limitations that will be applied to benefit acetaminophen products are as follow:

The coverage of aerochambers is limited to 1 per patient per 12 month period.

Astemizole Syrup is subject to the following limitation:

Glucose test strips are subject to the following limitations:

• The patient must be eligible for coverage under the Newfoundland and Labrador Prescription Drug Program (NLPDP) and be in receipt of a valid drug card.
• The patient must be a diabetic and be taking insulin or oral hypoglycemic medications OR
• The patient is being followed by a Diabetes Nurse Educator, Dietician, or Family Physician, with a letter to confirm same.

Only Glucose test strips included on the NLPDP Benefit List are covered.

Special Authorization must be requested from the Pharmaceutical Services Division for test strips for individuals not on insulin or oral hypoglycemic medications.

The liquid medication shall remain as a benefit but it’s coverage shall be limited to children under the age of twelve. The suppository strengths of 25mg, 50mg, and 100mg remain as benefits. While there is no formal benefit limitation applied to the suppositories at this time, it is hoped that their utilization shall be limited to patients who cannot medically take the oral formulation. The benefit limitations applied to the dimenhydrinate category are as follow:

* At this time this benefit limitation does not apply for dimenhydrinate liquid used as an ingredient in an extemporaneous preparation. Utilization will be monitored to determine if a limitation must be put in place for use in this circumstance.

The benefit limitation that applies to all benefit brands of docusate sodium syrup is as follows:

All brands of Loratidine Syrup are subject to the following limitation:

Methylphenidate products in any strength (10mg, 20mg, SR 20) are limited to use for children under the age of 16 or subject to the professional discretion of the dispensing pharmacist. If any pharmacist has concerns over a patients methylphenidate use they should contact the Department.

All of the following brands of prenatal vitamins are subject to benefit limitations.

These products are limited to use in patients who are pregnant and are to be dispensed in quantities of a minimum of 100 tablets.

As with all brands of cholestyramine, NLPDP only reimburses for the bulk product, coverage is not provided for the higher cost sachets. However, as Novo-Cholamine has the same din for both the bulk and sachet products, providers should note that reimbursement shall be limited to the cost of the bulk product.

Please note that for patients who require product(s) in any of the listed categories and yet do not meet the specified limitations, consideration will be given to provide the product under special authorization on receipt of supportive information from the prescribing physician to the Department of Health and Community Services.