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10.5.32 Pharmacy

The VWA can pay the reasonable costs of medication and other pharmacy items required as a result of a work-related injury or illness.

AC Act: S99 Liability of Authority and self-insurer

WIRC Act: S224 Liability of Authority and self-insurer

The VWA can only pay for medications and pharmacy items requested by registered medical practitioners or registered dentists and which are provided by pharmacists that are registered:

This section outlines the requirements of the legislation and the VWA’s policy regarding pharmacy services.

This section of the Claims Manual must be read in conjunction with the following:

Information relevant to the VWA’s Pharmacy Policies can be found at:

For more information on the entitlements of workers to PBS prescribed medications refer to: Medicare Australia.

Pharmacy provider

Direct billing by a pharmacy

Workers may wish to approach a pharmacy about whether they are willing to send invoices directly to the agent (direct billing).

If the pharmacist agrees to direct bill the agent, the worker should provide the pharmacist with the following:

For the VWA to pay the pharmacy for an item purchased from there, a worker must be able to show that the item is:

Workers who request complementary and over the counter medications and pharmacy items must be able to provide a request from their medical practitioner that confirms the pharmacy item is for the treatment of their work-related injury or illness. It is good practice for pharmacists to take a copy of this letter and keep it on the worker’s file in case the agent requests proof that particular items are injury related.

The VWA recommends that pharmacists check with the agent or ask the worker for confirmation that the agent has accepted liability for vitamins and minerals before agreeing to bill the agent directly.

Minimum invoicing requirements

Information regarding the minimum invoicing requirements can be found in the VWA Accounts Manual via Agent Online under the manuals tab.

Refer to the Pharmacy Fact Sheet ‘Requirements for invoicing the TAC and the VWA’ located on the VWA website at www.vwa.vic.gov.au.

Reimbursement to worker

Workers can pay for pharmacy items themselves and seek reimbursement from the agent of the reasonable costs of those items by providing a fully itemised receipt as proof of purchase.

Where the pharmacy item is available on the Pharmaceutical Benefits Scheme (PBS), the VWA will reimburse at the PBS rate, not at the private medication rate. If the pharmacy item is only listed as private medication and not available on the PBS, the VWA will reimburse the worker at the private medication rate if the costs of the medication are reasonable.

The services can be provided by any registered pharmacist.

Each pharmacy is required to register with the VWA to obtain a WorkCover provider number to enable payment of invoices.

If the pharmacy name or address details change, a new provider number will need to be allocated. Updated details should be faxed to the Provider Registration Branch of the VWA on 9641 1767. A letter with the new provider number will be mailed to the pharmacy.

See:

Entitlements - Medical and Like Services - General information

Information for Pharmacists

The VWA will pay for

The VWA will pay for the reasonable costs of medications and pharmacy items that meet all of the following criteria:

Erectile dysfunction medication

Erectile dysfunction is the inability to achieve or maintain penile erection. It is also known as impotence. Erectile dysfunction may occur as a result of injuries sustained in the workplace in the form of neurogenic, vasculogenic or psychogenic origins or as a side effect of medication used to treat another work-related injury or illness. Erectile dysfunction medication may be in an oral or injectable form.

See:

Erectile dysfunction medication

Process for erectile dysfunction medication

Glucosamine

Glucosamine is a natural product indicated for the management of osteoarthritis (OA) and the temporary relief of its associated pain. It is a precursor substance to the generation of glycosaminoglycans which make up to 50% of the composition of hyaluronic acid, a natural lubricant found in synovial (joint) fluid.

Studies on glucosamine indicate that it may delay the structural progression of OA and additionally decrease joint pain and increase range of movement.

When glucosamine can be paid for

The VWA can pay for glucosamine where it is:

See: Pharmacy Information - The VWA will pay for (except for ARTG registration requirement).

What can be paid for

As the Australian Register for Therapeutic Goods (ARTG) has only one registered product with a minimum 500mg dose of glucosamine, the VWA can make an exception and fund ARTG listed glucosamine products, provided they are administered consistent with current best practice, to a daily therapeutic dose of 1500mg.

Prior approval

To assess the reasonable costs of a request to fund glucosamine a written clinical rationale from a registered medical practitioner may be requested by the agent for consideration and approval.

Where glucosamine is requested for OA or articular cartilage damage, arthroscopic or radiological evidence must be available. The evidence may be summarised or provided with the written clinical rationale and include any other relevant documentation to confirm the diagnosis.

When glucosamine not will be paid for

The VWA will not pay for glucosamine where it is being used for spinal conditions as there is currently insufficient evidence to support the use of glucosamine for this application.

See also: Pharmacy Information - The VWA will not pay for

Drugs of dependence: schedule 8 and schedule 4 medications

The VWA supports the responsible, safe and legal prescribing of medications to help treat people with a work-related injury or illness.

This section of the pharmacy policy provides information to help ensure safe prescribing drugs of dependence. It follows best medical practice and State and Government laws and regulation and is in the interests of medical practitioners, workers and the community.

Drugs of dependence refers to some Schedule 4 medications plus all Schedule 8 medications. These medications have a therapeutic benefit, however they are potentially addictive and may result in significant negative health and social consequences if misused. For example, benzodiazepines, propoxyphene (Digesic, Doloxene), anorectic medications (Duromine) and anabolic steroids.

THPs should take additional precautions before prescribing Schedule 4 drugs of dependence. Refer: health.vic.gov.au/dpu

Certain dosages of drugs of dependence may require a Pharmaceuticals Benefits Scheme (PBS) Authority, please consult the PBS website for further details.

Schedule 8 medications

Schedule 8 medications are drugs of addiction as listed in the Drugs, Poisons and Controlled Substances Act 1981. They are controlled substances that require restriction of manufacture, supply, distribution, possession and use to reduce the risk of abuse, misuse and physical and psychological dependence. For example, morphine (Kanopol, MS-Contin), pethidine, oxycodone, (Oxycontin, Endone), methadone (Physeptone), hydromorphone (Dilaudid), flunitrazepam (Hypnodorm) and fentanyl (Durogesic).

Schedule 4 medications

These are labelled Prescription Only Medicine and include all other medications for which prescriptions are required, eg sleeping tablets, some pain killers (e.g. Panadeine Forte) and many others.

Refer: health.vic.gov.au/dpu

Why are schedule 8 and some schedule 4 medications considered drugs of dependence

Some Schedule 4 and all Schedule 8 medications have a legitimate therapeutic medical use, however, they also have a high risk potential for harm, dependence and accidental death from poisoning, if misused or overused. All drugs of dependence need to be controlled and restricted in their manufacture, supply, distribution, possession and use to reduce the risk of abuse and dependence. Long term use of such medications is often considered an ‘off-label’ use of that medication. If this applies then clinical justification is required before the VWA can consider funding the medication long-term.

Schedule 8 medications the VWA will pay for

The VWA will pay for Schedule 8 medications, prescribed through the PBS system in the treatment of a worker when:

In cases where quantities of Schedule 8 medications are above the PBS maximum quantity they must be prescribed on a PBS authority prescription.

See: Pharmacy information - The VWA can pay for

Schedule 8 medication restrictions

Due to the inherent risk of these medications and the State and Commonwealth government checks and balances in place to support their safe use, Schedule 8 medications should be prescribed through the PBS system, unless exceptional circumstances.

If a THP believes that PBS medications are not suitable and an exemption under the VWA policy is required, the THP must provide a written clinical rationale to the agent for consideration and approval.

If an exemption is not granted, payment of private scripts for Schedule 8 medications will not be paid.

See: Pharmacy information - The VWA will pay for

Guidance from the Department of Human Services (DHS) Drugs and Poisons Regulations Group, Victoria outlines that having multiple prescribers for drugs of dependence can be detrimental to the safety of the patient and therefore a patient should have a principal medical practitioner.

The Drugs and Poisons Unit recognises that within multi-practitioner clinics, more than one practitioner may treat individual patients. Provided one practitioner from the practice holds a valid permit and all prescribing is consistent with this permit, each treating medical practitioner from a clinic may prescribe under the one permit.

See: Multiple prescribers or dispensers for S8 and sedative medications

Permit required to prescribe schedule 8 medications

The Drugs, Poisons and Controlled Substances Act 1981 requires a THP to hold a permit from the DHS when it is necessary to prescribe a Schedule 8 medication for longer than eight weeks.

The permit system protects patients by enabling the coordination of their treatment with Schedule 8 medication by an individual medical practitioner who is authorised to prescribe them.

The above Act makes it an offence for a THP to prescribe, administer or supply a Schedule 8 medication to a person who they have reason to believe is drug dependent, unless they hold a permit issued by the DHS.

An individual permit from the Drugs and Poisons Regulation Group (DPRG) is required by the prescriber for each patient when treated with Schedule 8 medication in the following circumstances:

Note:

The Drugs and Poisons Regulation Group insists that an 8 week period is intended to relate to short term use and/or to allow the THP, who initiates treatment, time to assess the patient.

When consulted by a patient who is already taking a Schedule 8 medication and has indicated an intention to transfer from another clinic, THPs are strongly advised by the Drugs and Poisons Regulation Group to immediately apply for a permit.

This permit must be obtained and kept up to date by the THP or dentist. The agent may request to view a copy of the permit at any time.

When schedule 8 cannot be paid for

The VWA will not pay for Schedule 8 medications that:

Worker suffers a drug dependency

Where a worker suffers a drug dependency, the THP must notify the relevant State/Territory government department of this, as this is a legal requirement.

The agent should also be informed as they assess all requests for medications.

The VWA will not fund the medication unless evidence based clinical justification is provided that permits the medication to be used in the worker’s ongoing treatment.

Where to obtain further information on these medications

In Victoria, further information can be obtained from the:

Department of Human Services (DHS)
Drugs and Poisons Regulation Group
GPO Box 4057
MELBOURNE  VIC  3001

Tel:   1300 364 545
Fax:  1300 360 830

Web: health.vic.gov.au/dpu

Sedatives

The VWA supports payment of prescription sedatives for short-term use only. The VWA will pay for sedatives in the treatment of a work-related injury or illness provided clinical justification exists and the treater/prescriber adheres to the relevant prescribing requirements.

Sedative medications are recommended by medical practitioners for short-term use for sedation, muscle relaxation or for the relief of anxiety. Sedatives are occasionally used long-term for the treatment of epilepsy or spasticity.

Benzodiazepines are a class of sedatives. Long-term use of benzodiazepines can lead to dependence and can also result in memory impairment, motor incoordination, decreased reaction time and ataxia. Misuse or injection of sedatives can cause significant damage, possibly even death.

Hypnodorm (Flunitrazepam) is both a sedative and a Schedule 8 medication. For the purpose of this policy, hypnodorm is managed under the Schedule 8 medications policy.

In 2000, the Royal Australian College of General Practitioners (RACGP) released a list of ten guidelines for the safe prescribing of benzodiazepines. Two of these guidelines state that:

The VWA strongly encourages prior approval to be sought before the treatment is provided. This allows the VWA to determine whether the treatment is related to the work injury or illness, is a reasonable treatment option and is reasonably necessary and/or appropriate in the circumstances. It will also facilitate prompt payment of accounts for injury/illness-related treatment.

Sedative medications

In this policy, sedatives refer to the newer sedatives Zopiclone (eg Imovane), Zolpidem (eg Stilnox) as well as the benzodiazepine class of medications, including: Diazepam (eg Valium), Temazepam (eg Temaze), Nitrazepam (eg Mogadon). Alprazolam (eg Xanax, Kalma), Lorazepam (eg Ativan), Clonazepam (eg Ritrovil, Paxam) and Oxazepam (eg Serepax).

Sedative medications that the VWA will pay for

Sedatives prescribed for short-term use that are available on the Pharmaceutical Benefits Scheme (PBS) (prescribed in accordance with PBS indications).

The VWA can only consider paying for the following if requested by the prescribing medical practitioner and clinically justified:

Can the VWA pay for benzodiazepines for musculoskeletal pain due to muscle spasm

Based on current clinical guidelines, the VWA can only pay for benzodiazepines for musculoskeletal pain due to muscle spasm for a short period of time, eg one week. This restriction does not apply to spasticity caused by neurological conditions, such as traumatic brain injury or spinal cord injury.

Information the VWA requires to consider paying for sedatives beyond short-term use

Sedatives are recommended for short-term use only. If sedatives are expected to be prescribed beyond short-term use, the treater/prescriber must provide the following information to the agent:

The VWA will not pay for:

Topical non-steroidal anti-inflammatory medications (NSAIDS)

NSAIDs are medications that relieve pain, swelling, stiffness and inflammation.

Topical NSAIDs are creams or gels which are applied directly to the skin over the injured area. Topical NSAIDs include Feldene gel, Orudis and Voltaren Emulgel.

When topical NSAIDs can be paid

The VWA can pay for topical non-steroidal anti-inflammatory creams/gels that are used for a maximum of six weeks, as per product information, following a work-related injury or surgery for a work-related injury.

See: Pharmacy Information - The VWA will pay for

When topical NSAIDs will not be paid

The VWA will not pay for topical NSAIDs where: refer to Pharmacy Information - The VWA will not pay for.

Exceptional circumstances

Payment of topical NSAIDs beyond six weeks of the work-related injury or surgery can be considered in exceptional clinical circumstances.

To do so, a written clinical rationale from the medical practitioner must be provided to the agent for consideration and approval, confirming that the ongoing use of NSAID gels is required for the work-related injury. The clinical rationale for the long-term use of NSAID gels for the treatment of the injury and objective measures of improvement resulting from the continued use of Topical NSAIDs.

The VWA will not pay for

The VWA will not pay for medications and pharmacy items that:

Restrictions on quantities dispensed and bulk supply

The VWA will not pay for excessive quantities of medications except in exceptional circumstances, such as overseas travel. If a medical practitioner or dentist believes exceptional circumstances apply, a written clinical rationale must be provided to the agent for consideration and approval, before prescribing such medications. The maximum quantity of medications to be paid for is not to exceed 12 weeks.

This policy does not apply to Schedule 8 medications. Schedule 8 medications will not be funded for overseas travel or bulk supply.

The prescription must be endorsed by the prescribing medical practitioner or dentist as per regulation 24 of PBS Guidelines for dispensing repeat quantities.

 

10.5.32.1 - Process for assessing pharmacy requests and invoices

10.5.32.2 - Erectile dysfunction medication

10.5.32.3 - Private schedule 8 medication (with a PBS equivalent) - drug category 61