TELUS Health pharmacy reference guide

TELUS Health Web Site Carrier Number (Updated November 2013) What Causes A DUR (Drug Utilization Review)
For the most up-to-date pharmacy support information, please On the patient’s TELUS Health card, the first two digits of the Warning/Reject?
check online at: www.telushealth.com/pharmacysupport. Cardholder Identification Number identify the Carrier Number. For the majority of our policies, pharmacies will receive a warning
message on potential duplicate therapies/drug Interaction. Some
Useful tools on the website: 11 Great West Life 35 AGA policies may have selected to reject claims that require a drug
Pharmacy Manual Pharmacy Updates 12 PSHCP 36 CCQ (Medic Constructions) utilization review.
Pseudo-DIN List Diabetic Pseudo-DIN List 16 Sun Life Financial 37 WorkSafe BC
Compound Submission and Eligibility Guidelines 20 Standard Life 40 Global
22 Desjardins 44 Johnston Group
(Chamber of Commerce) 49 WSIB Duplicate Therapy DUR
Some frequently used forms available:
23 UL Mutual 57 PBAS Indicates that 2 or more of the same classification of drug have
Pharmacy Provider Change Request - make a change to 29 Equitable Life 62 La Capitale been historically prescribed and may still be active in the patient’s
your store contact information, dispensing fee, payment option or 32 DA Townley 80 eSampling body. This could result in a drug concentration higher or lower
banking information. than the prescriber had intended.
Adjustment to Account Request - reverse a prescription claim
that is older than 90 days.
Relationship Code and Date of Birth Drug Interaction DUR
Request for Claim Re-transmission – request that
If you get a message “Invalid date of Birth”, confirm the date of
TELUS Health “open a window” for re-transmitting a claim online; Cautions against possible adverse effects of 2 or more
birth (DOB) with your patient and the relationship of the patient to
these requests are reviewed on a case by case basis. To help medications when taken together.
the main cardholder.
expedite your request, ensure the correct form is used, all sections
are completed, and all required documentation is submitted. Only potentially harmful drug interactions (significance level 1) will
The name on the TELUS Health card may be the name of the
reject payment of the claim and require the pharmacists to use
employee, a spouse or dependent child. Ensure the correct
their professional judgment based on patient specific factors. All
relationship code is selected when submitting claims.
other check results are sent to the pharmacist as text warning
messages only.
Relationship Codes*
Employee (primary cardholder) 01 If the therapy is appropriate, you may override the reject code
with the most appropriate intervention code from the following list.
Spouse 02
UA Consulted prescriber and filled Rx as written.
Dependent child 03
UB Consulted prescriber and changed dose.
Overage dependent child 04
UC Consulted prescriber and changed instructions for use.
Overage disabled dependent child 05
UD Consulted Prescriber and changed drug
* Relationship codes may vary depending on pharmacy software.
UE Consulted prescriber and changed quantity.
UF Patient gave adequate explanation. Rx filled as written.
The ages at which benefits cease for a dependent child
(i.e., 18, 19, 21 or 25) vary for cardholders with family coverage. UG Cautioned patient. Rx filled as written.
If the dependent is in full-time attendance at school, and has UI Consulted other source. Rx filled as written.
been approved for coverage, then coverage would be continued
UJ Consulted other sources. Altered Rx and filled.
until he/she reaches the maximum age as determined for
overage dependents. UN Assessed patient. Therapy is appropriate.

Note: The TELUS Health Pharmacy Manual and Pharmacy Updates form part of (Detailed procedures on processing claims for Incorrect DOB are explained in
the Provider Agreement. The most current versions are available on our Web Site. the TELUS Health Pharmacy Manual.)
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TELUS Health pharmacy reference guide
Refill Too Soon Maintenance Program
As per TELUS Health policy: DA, DB, DE Intervention Codes A voluntary program designed to encourage the dispensing
At least two thirds of the previously dispensed medication “DA” and “DB” intervention codes are used for of a larger day supply to patients who are taking a medication
must be depleted prior to a second supply being dispensed. coordinating a claim between 2 payers (or drug plans). for a long duration. For patients on this program, some claims
This is called coordination of benefits (COB). will get the warning message “DRUG ELIGIBLE FOR 100 DAY
Should there be a documented change in dosage on the MAINT QUANTITY.” This is to encourage patients to get a larger
second claim, the two thirds rule would no longer apply. DA = S
 econdary claim, first payer was a provincially
drug supply for medications intended for treatment of a chronic
sponsored plan.
If you obtain a “Refill Too Soon” message and your records condition. Alternatively, some claims for acute drugs may be
indicate that the patient is eligible for their next refill, please DB = Secondary claim, first payer was a private plan. rejected with the message “RESUBMIT ONE MONTH SUPPLY.”
contact the TELUS Health Pharmacy Support Centre prior to DE = F
 irst payer was the Workers’ Compensation Board After three consecutive one-month prescriptions, the patient will
dispensing the second claim. It is possible that an identical of B.C., (WorkSafe BC), but was adjudicated be eligible to receive a three-month supply.
prescription was dispensed at another pharmacy and should through Pharmacare for DUR.
therefore not be dispensed again.
MG Override - various reasons
Use this code if for any reason the patient chooses not to
Compounds Trial Program participate in the above voluntary programs, or if you feel it is
Compounds are generally eligible if the primary active ingredient A voluntary program designed to promote the dispensing appropriate to override the programs.
is covered under the patient’s plan. Common reasons of smaller quantities of new prescription drugs that have a
compounds are deemed ineligible include, but are not limited to: high incidence of side effects. This discourages waste if the For audit purposes, TELUS Health requires that the pharmacy
medication is not tolerated. document all relevant details about the prescription to support
A commercial product of the same strength is available for sale
the selection of overrides.
The primary ingredient is not covered under the patient’s plan, Procedure for Trial Program
such as
a) OTCs 1 For drugs eligible under the Trial Program, you will receive
b) Natural/Homeopathic products the message “INVALID DAYS SUPPLY - TRIAL DRUG
c) Investigational PROGRAM.”
The product is for cosmetic use 2 Ask the patient if he/she would like to participate in the Trial
Program. If the patient refuses, use the appropriate override
The product contains an ineligible base/ingredient
code. If the patient accepts, you may resubmit a 7-day
supply of the medication.
If you have any questions about how to transmit a compound
claim, or to determine compound eligibility, contact the 3 Contact the patient after 5 or 6 days to determine if the drug
TELUS Health Pharmacy Support Centre. is effective and tolerated.
4 If the drug is tolerated, the balance of the prescription can
For compound verification for a patient, you will be asked TELUS Health Pharmacy Support Centre
be filled and the pharmacy is eligible to receive a second
to provide ALL compound ingredients with their strength (if dispensing fee. Telephone: 1 800 668-1608
applicable). The agent may then provide you with a compound
PIN for submission of your claim. 5 If the drug is not tolerated, you may choose to contact the Monday to Friday 8 am - midnight (EST)
prescribing physician to request an alternative therapy. Saturday and Sunday 9 am - 8 pm (EST)
A copy of the up-to-date compound guidelines is available at the 6 You may submit a claim for the alternative therapy, which may Public Holidays Noon - 8 pm (EST)
following link: also be subject to the Trial Program. Civic Holiday 9 am - 8 pm (EST)
http://www.telushealth.com/docs/assure-claims/
7 If no alternative therapy is prescribed after consultation Eastern Time (EST)
compound-sub- mission-and-eligibility-guidelines.
pdf?sfvrsn=11 with the prescribing physician, you may be eligible to
receive a cognitive fee. The cognitive fee can be billed to
TELUS Health using PIN number 19000001.
See Over