Effective September 1, 2011, the first stage of expanded services in which a potential drug related problem is identified at the time of dispensing is renamed the Pharmaceutical Opinion Program and will now include a clinical intervention identified by the pharmacist at the time of conducting a MedsCheck medication review.

The first stage of expanded services, now referred to as the Pharmaceutical Opinion Program is a clinical intervention that occurs at the time of dispensing a prescription or when conducting a MedsCheck review when a pharmacist identifies a potential concern that requires follow-up with the prescriber. Based on consultation with the prescriber, the prescription may not be dispensed, may be dispensed as prescribed or the prescription therapy may be adjusted (includes adding or discontinuing a prescription).

Only Ontario Drug Benefit recipients are eligible for the pharmaceutical opinion program in Ontario.

The objectives of the pharmaceutical opinion program include:

• promoting healthier patient outcomes;
• improving and optimizing drug therapy;
• ensuring benefits are used appropriately; and
• reducing inappropriate drug use and drug wastage.

When the pharmacist makes a recommendation to the prescriber in a pharmaceutical opinion, there are three possible outcomes:

• Not Filled: The prescription is not filled as a result of a confirmed forgery or due to a clinical concern based on consultation with the prescriber.
• No Change: Recommendations by the pharmacist were discussed with the prescriber and no change to drug therapy was made to the prescription or the patient’s profile. Prescription was filled as prescribed no change to MedsCheck profile (if applicable)
• Change: Recommendations by the pharmacist were discussed with the prescriber and led to a change in therapy as prescribed.

No. Community pharmacists have historically contacted physicians regarding potential drug related problems that are identified at the time of dispensing a prescription. The ministry recognizes the value added benefits to patient drug therapy and patient safety as a result of a pharmacist’s clinical intervention and recommendation to the prescriber regarding the issues at hand.

No. Community pharmacists on occasion identify potential drug related problems when conducting a MedsCheck and as a standard of care the pharmacist takes action by either working to resolve the issue or by referring the patient to the appropriate health care professional.

In June 2010, the Minister of Health and Long-Term Care announced additional funding towards pharmacist’s professional services that included the MedsCheck expanded programs that were launched in September 2010 and the development of a special working group of community pharmacists to provide advice on professional pharmacy services that could be implemented in the near future. The first stage of expanded services was introduced on the recommendation of the special working group.

The first stage of expanded services was originally implemented on April 1, 2011 for potential drug related problems identified at the time of dispensing. The program was renamed, Pharmaceutical Opinion Program and expanded to include clinical interventions identified when conducting a MedsCheck medication review effective September 1, 2011.

The amount paid to the pharmacy through the ministry’s Health Network System is $15 per applicable prescription in which the pharmacist identifies a drug related problem at the time of dispensing a new or repeat prescription and/or at the time of conducting a MedsCheck medication review.

No, the pharmaceutical opinion service is a recognized pharmacist professional service.

Yes, effective September 1, 2011 the pharmaceutical opinion may be claimed as a result of a pharmacist identifying a potential drug related problem resulting from a MedsCheck review.

A drug related problem (DRP) – also referred to as a drug therapy problem – is an undesirable event or risk(s) experienced by the patient that involve or are suspected to involve drug therapy and that inhibit or delay him/her from achieving the desired goals of therapy¹. The first stage of expanded services uses eight intervention criteria; the DRP identified during a MedsCheck review uses the first seven intervention criteria.

¹Strand L.M., Morley P.C., Cipolle, R. J., Pharmaceutical Care Practice, The Clinician’s Guide, 2nd ed. McGraw-Hill, 2004, p 12.

The potential drug related problems that may be identified:

1. Therapeutic duplication; drug may not be necessary
2. Requires drug; needs additional drug therapy
3. Sub-optimal response to a drug
4. Dosage too low
5. Adverse drug reaction
6. Dangerously high dose; potential overuse; abuse
7. Non-compliance / Adherence
8. Confirmed forgery or falsified prescription

The Drug Related Problems are further defined in the detailed program information.

All patient problems involving medications can be categorized into one of the eight types of drug related problems outlined in the ministry’s first stage of expanded services. These include any and all side effects, toxic reactions, treatment failures, or the need for additive, synergistic, or preventative medications, as well as non-compliance.

Provided a drug related problem is identified during the follow-up review whereby the pharmacist makes a recommendation to the physician on the drug therapy issue, the pharmacist may proceed with the appropriate outcome based on the program criteria. For example: If there are no changes to a patient drug therapy as a result of the discussion with the physician, the “no change” PIN should be used.  If changes were recommended/made to therapy i.e., different product, strength or dosage form, adding a drug or discontinuing a drug, the PIN indicating that a change was made should be used.

In this situation the pharmacist should use the PIN for Change to Prescription Therapy as therapy is added.

Confirmation with the prescriber regarding a duplication of therapy requires that a drug be discontinued. Should a drug be discontinued under the program, the PIN for Change to Prescription Therapy should be used.

Yes. Provided the pharmacist follows through with the recommendation to the physician along with the required documentation this may be claimed as a billable service using the PIN for Change to prescription therapy.

A pharmaceutical opinion occurs in a community pharmacy at the time of dispensing a new or repeat prescription that is presented by the patient to the pharmacy staff. A pharmaceutical opinion may also occur at the time of conducting a MedsCheck medication review. The location of MedsCheck medication reviews are outlined in the respective MedsCheck program materials.

If the pharmacist identifies a potential drug related problem at the time of dispensing a new or repeat prescription he/she will contact the physician and make a recommendation regarding the drug therapy issue. Similarly, if a potential DRP is identified during the MedsCheck review, the pharmacist will contact the prescriber with the recommendation and collaborative outcome.

Pharmacists may contact the prescriber as they would for any prescription related issue by telephone or by fax or other means that is considered appropriate and secure.

Expertise in medications and medication use is one of the four domains of a Canadian pharmacist’s standards of care². Pharmacists who identify a potential drug related problem are therefore expected to provide a recommendation to the physician that is in the best interest of the patient’s drug therapy. Without a recommendation regarding drug therapy and documentation, the interaction does not meet the pharmaceutical opinion service requirements.

²Model Standards of Practice for Canadian Pharmacists
http://129.128.180.43/Content_Files/Files/Model_Standards_of_Prac_for_Cdn_Pharm_March09.pdf

If there is no documentation or incomplete documentation regarding the pharmaceutical opinion program requirements, the claim is subject to recovery.

No. While the ministry does not provide a standardized form for the pharmaceutical opinion program, pharmacists may develop their own form based on the in-depth documentation criteria outlined under the program requirements.

The pharmacist may accept the response from the physician over the phone and transcribe the required information unless the outcome is a change in drug therapy that requires a written prescription by law.

Yes. The patient needs to know the outcome of the pharmaceutical opinion and the pharmacist is accountable for contacting the patient.

Documentation must be on the patient’s electronic profile or on the prescription hardcopy and in a readily retrievable format or if applicable on the MedsCheck documentation. At a minimum, pharmacists must outline the outcome, the drug related problem, the recommendation to the prescriber and any other comments to substantiate the outcome. In addition, the date, the name of the prescriber that was contacted and the pharmacist’s signature are required.

The original prescription (or copy) whether verbal or written, along with all signed and dated documentation must be maintained on site at the pharmacy in a readily retrievable format for a minimum of 2 years for the purposes of audit under the Ontario Drug Benefit program. The pharmaceutical opinion record is cross-reference to the prescription that it is aligned with.

All records relating to the pharmaceutical opinion claim and the prescription that it is cross-reference with (or the MedsCheck documents) are maintained on site at the pharmacy in a readily retrievable format for a minimum of 2 years for the purposes of audit under the Ontario Drug Benefit program. All patient health records must be retained by the pharmacist in a readily retrievable format and kept on file at the pharmacy for a minimum period of ten years or as per O.Reg. 58/11 of the Drug and Pharmacies Regulation Act.

A pharmaceutical opinion may be conducted as identified by the pharmacist for new or repeat prescriptions or as a result of conducting a MedsCheck review according to program criteria.

No.  Pharmacists that are registered as Part A with the Ontario College of Pharmacists are qualified to conduct a pharmaceutical opinion.

No, calling a prescriber to only clarify a prescription dose or dosage form or concentration does not meet the requirements of a pharmaceutical opinion for reimbursement. In addition, contacting the prescriber due to missing information on a prescription, clarifying a patient’s contact information or the prescriber’s handwriting are also not applicable.

No. Contacting the prescriber to change the prescription to a product that is in your inventory is not considered a pharmaceutical opinion for reimbursement. A pharmaceutical opinion is a clinical recommendation based on a potential drug related problem and not based on whether the item is in stock.

No. The act of placing the prescription on hold is not considered a pharmaceutical opinion for reimbursement.

No. Pharmacists are not eligible to receive a pharmaceutical opinion payment for claims that are already captured through the Health Network System (HNS) including “fill too soon” or “too late”. However, if in addition to the HNS message alert the pharmacist made a valid recommendation to the prescriber that aligns with the pharmaceutical opinion drug related problems, then it is valid.

No. Providing a patient profile or a list of medications to the prescriber without making a recommendation to the prescription is not considered a pharmaceutical opinion or a MedsCheck service for reimbursement.

No. Providing a MedsCheck medication review to the prescriber without making a recommendation to the prescription is not considered a pharmaceutical opinion for reimbursement nor is it a billable service under the MedsCheck program.

No. Contacting the prescriber to change a medication to an eligible benefit is not considered a pharmaceutical opinion for reimbursement.

Yes. Provided the pharmacist has undergone the appropriate steps in the program including documentation of the clinical value of the drug and what has occurred regarding the patient’s drug therapy, then the scenario mentioned would apply.

Pharmacist’s steps to take under this program:

• A new or repeat Rx
• A DRP that a pharmacist has identified
• A recommendation to the MD regarding the issue
• The communication exchange between MD and RPh
• An outcome is achieved (one of 3)
• Documentation of the issue including cross-reference to the prescription.
• Appropriate follow-up with the patient

No. Areochambers, diagnostic test strips and other medical devices that are associated with drug therapy are not considered as meeting the program criteria of one of the seven drug related problems. In addition, medical devices are not defined as drugs or as natural health products by Health Canada.

Yes, there is a list of what is not included in pharmaceutical opinion information however, the list is not inclusive. Please refer to the program information for more details.

The ministry amended the regulations that extended the period for the $1 transition fee for pharmacies from April 1, 2011 to June 30, 2011.