Dispensing to Bankmed Patients

Date: 9 Aug 2018

ACUTE PSYCHIATRY MEDICINE MANAGEMENT

In line with Bankmed’s philosophy of good clinical governance, Bankmed has implemented measures to ensure the appropriate use of specific medicines that have high risk for patient dependence.

Anxiolytics should not be used for a period longer than 2 weeks, therefore Bankmed has implemented a quantity limit on acute to prevent chronic use of these drugs and thereby ensuring clinically appropriate use.

Sedatives and hypnotics should not be used as long-term therapy, therefore Bankmed has implemented a quantity limit on acute to prevent chronic use of these drugs and thereby ensuring clinically appropriate use.

Furthermore antidepressants are used to treat a variety of chronic conditions. To ensure these drugs are funded from the appropriate Chronic benefit, Bankmed will only allow 2 fills of antidepressants on Acute. Should the patient need to use the antidepressants on an ongoing basis they will need to register their condition as Chronic.

The following RMR’s may be returned in the event that the allowed period has been exceeded.

1. RMR 558 – Indiv Prtcl Qty (Individual Protocol Quantity Exceeded) will be returned in the following scenarios:

For sedatives and hypnotics, 30 days’ supply would be allowed over a 90 day period. If the patient claims more than this allowed limit, the claim will reject with the above RMR code. Please inform the member that they have exceeded the clinically appropriate limits for these drugs.

For Anxiolytics, 2 weeks’ supply would be allowed every 90 days. If the patient claims more than this allowed limit, the claim will reject with the above RMR code. Please inform the member that they have exceeded the clinically appropriate limits for these drugs.

2. RMR 315 – Pre-auth required (Call Scheme for authorization) will be returned for the below scenario:

For antidepressants, a warning message is sent back to the pharmacy during the first 2 fills indicating the member must apply for chronic benefits. The third fill will be rejected with the above RMR code. The member will then need to register for chronic to access antidepressants. Note the Core Saver plan is excluded from this rule as Depression is not covered as a chronic condition on this plan.

Brought to you by Medinol Medical Billing Software