Adrienne Horrocks & Alison Bonfield

Adrienne Horrocks & Alison Bonfield
Drug Tariff and Check34 Adrienne Horrocks & Alison Bonfield

Objectives for today Understand where dispensing income may be affected How to improve dispensing processes and top tips on receiving, processing and sorting prescriptions Understand the importance of maximising income through correct endorsement Introduction to and how it can help contractors

Stages where errors often arise
Receiving a prescription Dispensing/endorsing Prescription sorting Prescription submission ! Errors can occur during these stages of the dispensing process

Receiving a prescription
Complete the reverse of the Rx Collect the correct number of Rx charges Check patient exemption status is correct Check for missing prescriber codes Check prescribing rights of the prescriber Check the validity of the Rx Check for out of date prescription forms FP10SS FP10SS 0406 Checks when receiving a prescription The checks taken when you receive a prescription are incredibly important when it comes to ensuring correct payment. One of the most important factors is the filling out of the back of the prescription form. A consequence of the forms not being filled out correctly could lead to prescription switching (which we will cover later on in the presentation). Making sure you charge correctly is particularly important when there is a prescription price change or for multiple charge items eg hosiery When receiving a prescription, you will also need to confirm the forms validity as only certain types of prescription forms can be dispensed on the NHS so it is important that pharmacy staff are able to identify them. Also making sure that it the latest version of the form.

Missing prescriber codes If a prescriber code is missing
NHSBSA may return the script to pharmacy This could lead to a delay in payment Pharmacy could potentially lose money Ibandronic acid 50mg tabs 1OD 28 tabs Baclofen 10mg tabs 1OD 28 tabs Rx submitted in December January Ibandronic acid tablets £ £8.63 Baclofen tablets £ £2.99 Total cost of drugs £ £11.62 Difference ─ £4.33 Loss to the pharmacy = £4.33 GP code Since April 2013, there has been a requirement for NHS prescription forms (except for those issued by a Dental Practitioners) to have the prescriber code on it. This code links the prescriber to the practice where they work. NHSBSA use this code to recharge the costs to the correct area. Contractors therefore need to check prescriptions and attempt to identify and insert codes where any are missing. Where codes are missing, there may be a delay in payment for that prescription. You will not be paid until the prescription has been returned to the NHS BSA with the missing prescriber codes added to the form. If you are unable to identify a code, the prescription should be endorsed to say this and then returned to nhsbsa. When the prescription is resubmitted, it will be priced according to that month’s rules. It is important to note that pricing may be different to when the prescription was originally submitted for payment (Drug Tariff prices may change for example Category M) In this example, if the prescription with a missing code was submitted in December. However it was returned to the pharmacy and the pharmacist added the missing code and re-submitted the prescription with January bundle. The prices for both drugs changed in Janaury resulting in a loss of £4.33 compounded further by a delay in payment. For very expensive items this can have a significant cash flow impact on the pharmacy

Areas where errors commonly arise
Unlicensed Specials/Imports Broken bulk claims (BB) Out of pocket expenses Expensive Items Doctor’s signature Supplementary information Not dispensed Red Separator items Flavours Endorsing Switching

Unlicensed specials and imports
‘Special obtained’ Specials Unlicensed medicinal products – no UK marketing authorisation Unlicensed in UK – licensed or available from another country Lines which wholesalers do not routinely stock – a ‘special obtained’ item is not the same as a Special Contractors can often confuse a special obtained with an unlicensed special. The NPA receives several queries regarding specials and special obtained and the differences between them, which I will explain. An unlicensed special is a medicinal product which does not have a UK Marketing Authorisation. Unlicensed specials made to order will come with a specials manufacturer number, which can be found on the Certificate of Conformity (COC) or Certificate of Analysis (COA). Extemporaneously made items will usually have been made up in the pharmacy. An import is also an unlicensed preparation but is sourced from another country where the product may be licensed. Imports will have an importer’s licence number on the accompanying paperwork. A special obtained may be a licensed medicine, food supplement or an appliance, which is not routinely stocked by wholesalers. The wholesaler would seek to obtain it especially for the pharmacy. Some wholesalers/suppliers do not help too as they may not make it clear whether the product ordered and sourced is a special obtained or unlicensed special. For example a supplier may classify a special obtained as being unlicensed specials. This can lead to confusion amongst staff at the point of dispensing.

Specials and ‘special obtained’ – endorsing
Imports Special Obtain Special SP (ED if manufactured under Section 10 exemption) SP OOP or XP (EPS) Reason for claim Total amount (for claims over 50p) So how do we endorse specials and special obtained for out of pocket expenses? For specials – SP or ED if manufactured under section 10 exemption For imports – SP Special obtained – OOP or XP for EPS prescriptions. You would also need to endorse the reason for claim and the total amount once it has gone over the claims threshold of 50p.

Item listed in Part VIIIB
Specials endorsing Item listed in Part VIIIB Endorse ‘SP’ or (‘ED’ if made by pharmacy) Volume dispensed (where this is different from the quantity prescribed) No other endorsements required Bisoprolol 1.25mg/5mL oral solution 100mL SP Products that are listed in Part 8B of the drug tariff and the price listed is the price that is paid. Even if a higher price was paid by the contractor and this price was endorsed on the prescription, ONLY the Drug Tariff price will be paid along with the capped fee of £20 for OOPE when SP is endorses. Therefore you need to make sure that before placing an ordering, you source the item from a specials supplier who is able to supply the item at the Drug tariff price or lower to minimise loss of income for the pharmacy In this instance, because the medicine is listed in Part 8B, you would simply endorse the letter SP if you have incurred OOP to claim back the £20 fee. If the quantity prescribed is more than this minimum volume, reimbursement will be paid on that price plus the 1ml or 1g list price for every additional 1ml or 1g prescribed (unless the item is a special container). (This price per ml or g is also listed in the DT.)

Item NOT listed in Part VIIIB
Specials endorsing Item NOT listed in Part VIIIB Endorse ‘SP’ or (‘ED’ if made by pharmacy) Amount dispensed over pack size used for example 60/60 Price of pack size used (minus discount and rebates) MHRA specials/ importers licence number Batch number SP 60/60 £89.15 per pk Licence Batch 121549 Acetylcysteine capsules 600mg 1OD 60 capsules This medicine is not listed in part 8b of the drug tariff, therefore you would need to endorse the following: -Net price-minus any discounts or rebates offered by the supplier -Batch number of the product can be found on the product itself or on the certificate of conformity -The letters SP to claim the OOP expense of £20 -Manufacturers specials license number or the importers license number if the product is imported. This will be stated on the COC also. -amount dispensed over pack size used

Co-proxamol tablets endorsement
Co-proxamol tablets were deleted from Part VIIIA of the England and Wales Drug Tariff in December 2015 NHS Prescription Services has co-proxamol listed as an unlicensed special Prescriptions would therefore need to be endorsed as a non part VIIIB special In addition, the prescription will need to be placed in a red separator

Specials endorsing – extemporaneously dispensed
Product manufactured under the Section 10 exemption ED Made in pharmacy Made by 3rdparty Endorse ED Name, quantity and cost of each ingredient used Endorse BB for any ingredients Endorse ED When it comes to endorsing specials which are extemporaneously dispensed by the contractor or 3rd party manufacturer under the Section 10 exemption from the Medicines Act 1968, contractors will need to endorse the following ED for costs incurred in obtaining the item. If special made by a contractor also include names, quantities and cost of each ingredient BB can be claimed on the ingredients used if applicable.

For dispensing Specials
Endorse ‘SP’ or ‘ED’ DO NOT simply endorse £20 P+P Use the Dictionary of Medicines and Medical Devices browser (dm+d) Sort using red separator Compare prices of specials from different suppliers Some PMRs will automatically pick up if a product is an unlicensed special or not. If it does not then there are a few different ways in which you can check: -Either on DM+D -By checking with your wholesaler- some wholesalers will tell you whether a product is a special/import or special obtain. - By calling the NPA However some suppliers may not use the correct terminology in describing a product and may list a special obtain item as an unlicensed specials or vice versa. So double check before ordering as you may not be able to claim any additional costs or any out of pocket expenses incurred for certain products.

Broken Bulk Broken Bulk CANNOT be claimed on any the following:
All unlicensed medicines (unless claiming for ingredients used to prepare an unlicensed special extemporaneously dispensed) Category A and M products (reimbursement price of the smallest pack less than £50) Appliances (Part IXA) Chemical reagents (Part IXR) Special containers BB 50 /100 Bromocriptine 10mg capsules 50 capsules When a Broken Bulk claim is accepted, pharmacy contractors will be reimbursed for the complete pack dispensed. Subsequent prescriptions received during the next six months will be deemed to have been supplied from the remainder. During this time, no further payment will be made other than fees and consumable allowances until the remainder has been used up BB cannot be claimed on: (read from above) In summary, you can claim BB on the following products Items listed in in Part VIIIA Category C Items listed in Part VIIIA Category A and M products with smallest listed pack size of £50 or over Readily available medicinal products outside of Part VIIIA Appliances listed in Part IXB Appliances listed in Part IXC Ingredients used to prepare an unlicensed special (extemporaneously dispensing)

Broken Bulk Endorse ‘BB’ with amount dispensed over pack size used
Sort forms using red separator If red separator is not used, the form will not be seen by a claims handler and the item will be priced as ordered ! Mark container with date BB claimed New BB claim can be made after 6 months Endorse BB with amount dispensed over pack size used, Rx for BB need to go into the red separator. REMEMBER that prescriptions with broken bulk endorsements need to be placed in red separators. If they are not placed in the separators then they will not be seen by a handler and they are priced as ordered by the ICR software (intelligent character recognition) programme Another useful tip is to mark the container with the date BB claimed, as you can only make a new BB claim again after 6 months – any further prescription received for the same item within six months will not result in any further payment. After six months the NHS Prescription Services will write off any balance and pharmacies are then entitled to make further claims for BB on the same product if necessary. Pharmacies can only claim broken bulk if it is unlikely that the product will be dispensed again in the next six months. NHS Prescription Services has confirmed that products which are eligible for broken bulk claims and have a limited expiry once opened (for example 28 days), will be passed for the claim as stability information is not looked at for reimbursement purposes.

Out of pocket expenses OOP can be claimed on the following products: Part VIIIA Category C only Appliances in Part IXB Appliances in Part IXC Readily available medicinal products outside of Part VIIIA Products in ACBS list (gluten free items, fortified drinks etc) OOP Details of the claim e.g. postage Amount Can I claim out of pocket expenses on a product? is a very common question that we encounter from our members daily. It is possible, in exceptional circumstances for example if the item is one which you rarely supply, to claim out-of- pocket expenses for some items dispensed. Out-of- pocket expenses are expenses incurred in obtaining the drug or appliance. You CAN claim out-of-pocket expenses on: * drugs (except those in Part VIIIa, category A or category M of the Drug Tariff) * drugs in Part VIIIB, currently capped at £20 - please see record below * stoma and incontinence appliances in Part IXC and Part IXB of the Drug Tariff * oxygen. You CANNOT claim out-of-pocket expenses on: * drugs in Part VIIIA, category A or category M of the Drug Tariff * dressings, bandages etc (everything) in Part IXA of the Drug Tariff * catheters and suprapubic appliances in Part IXA of the Drug Tariff * reagents. The most common out-of-pocket expenses which can be claimed include postage and carriage and telephone calls to order items from manufacturers, however you can claim out-of-pocket expenses for telephone calls made to the prescriber. OOP expense claims are subject to a minimum threshold of 50p, but once the threshold has been reached those claims will be paid in full; therefore, claims need to total 51p or more to be accepted Just like BB scripts, you MUST place scripts with out of pocket expense claims in the red separators In a particular month, If the ‘No Cheaper Stock Obtainable” concession has been applied to a product that is in Part VIIIA category A or M, any out-of-pocket expenses incurred in obtaining that product can only be claimed in that month. Out-of-pocket expenses can also be claimed on borderline substances on the ACBS list of the Drug Tariff.

Out of pocket expenses Endorse ‘OOP’ (or ‘XP’ for EPS), details of claim and amount to claim. ‘SP’ endorsement is used for specials Place in a red separator. If not placed, it will not be seen by a claims handler OOP cannot be claimed for: appliances in Part IXA and Part IXR e.g. dressings, catheters, reagents Category A and category M drugs in Part VIIIA Only endorse OOP or XP – no other variations will be accepted The “OOP” or “XP” endorsement cannot be used on prescriptions for unlicensed specials and imports. Instead contractors are entitled to claim the fixed fee (currently £20) as discussed earlier. OOP can also be claimed for: Minimum order surcharges – this can be claimed as an out of pocket expense if the order relates to a specific product where contractor has incurred additional charges Cost of taxi or postage and packaging when transferring a product from one pharmacy to another (in order to support patient care) OOP cannot be claimed for Wholesaler fuel surcharges Appliances NHS pharmacy contractors are not contractually obliged to supply appliances that would not normally be supplied in the course of their business. Therefore if a contractor is faced with making a financial loss through dispensing an appliance, they may choose not to dispense it.

Expensive items An expensive item is any item (drug or appliance)
that has a NIC of £100 or more Fee of 2% payable per prescription item Expensive items can significantly affect pharmacy cash flow as full payment is received THREE months after dispensing Very expensive items can affect the AIV which in turn can affect the advance payment received An expensive item is any item (drug or appliance) that has a NIC (net ingredient cost) of £100 or more An expensive prescription fee of 2% is payable for each prescription item with a net ingredient cost of £100 or more. This fee is applicable per prescription item, not per prescription form. The average item value of a pharmacy can be affected by expensive items and is calculated by using the total of drugs and appliance costs plus fees, less the value of MURs, NMS and AURs, divided by the total number of professional fees received by the pharmacy. Fluctuations in AIV can have a huge impact on pharmacy cash flow. A large number of expensive items dispensed in a single month can increase the AIV which in turn can increase the level of advance payment a contractor receives. On the other hand, a lower AIV can result in a reduced advance payment received by the contractor which may not help cover the costs of ordering very expensive items in the current dispensing month

Expensive items Place in a red separator
Highlight scripts for expensive items during the dispensing process Sort red separator scripts daily to avoid them being misfiled Keep records of all expensive items dispensed per month to allow for reconciliation checks with FP34C Claims for advance payment for a high cost drug can be made via the Regional Team (previously area team – AT), where RTs have such schemes in place. If the RT agrees to the request a payment will be made to the pharmacy via the Local Payment Application. The pharmacy then submits the prescription for payment as normal and advance that has been made is recovered when the payment for the item goes on to the schedule. As with BB and OOP scripts, prescriptions for expensive items also need to be filed using a red separator. During the dispensing process, It may be easier to highlight or mark the prescription using a removable sticker or with a annotation of £, or BB or OOP so that when scripts are sorted they are easier to recognise If prescriptions cannot be sorted daily then aim for every other day or at least twice weekly to avoid the possibility that scripts are filed incorrectly. Contractors are recommended to keep a record of all Expensive items dispensed and submitted to the NHSBSA each month to help perform reconciliation checks against your Schedule of Payment. These records can be kept in a separate folder along with the photocopy of the FP34c submission document.

Doctor’s signature Prescription not placed in red separator
Doctor’s signature has obscured the quantity ordered for Digoxin tabs Item priced for 8 tablets instead of 28 tablets If placed in a red separator, script would be processed manually by a claims handler Mefenamic acid 500mg tabs 1OD 28 tabs Digoxin 125mcg tabs 1OD 28 tabs Joe bloggs Where the doctors signature can also have an impact on payment. In this example the drs signature has obscured the quantity for the digoxin tablets and as the rx was not put in the red separator to be checked by a handler the prescription is priced for 8 tablets instead of 28. If it was placed in the red separator than it would be priced by a handler who can see the correct quantity.

Supplementary product information
Supplementary information included as part of dosage can be missed by the pricing systems Pricing authority will price for standard formulations instead of preservative free If placed in a red separator, script would be processed manually by a claims handler Main product information field Carmellose 0.5% eye drops 2 drops in both eyes bd Preservative free 10mL Supplementary product information , for example, a particular brand or the words “preservative free”, should be written as part of the main product description in the first line and not in the body of the prescription (with dosage instructions for example) . If written as part of the dosage instructions or after the quantity, the prescription should be placed in the red separator so that they can be priced manually. If not placed in a red separator the ICR scanner may not pick up the supplementary information which could in turn lead to incorrect payment There are separate rules for EPS prescriptions which we will cover later. Supplementary information

Not dispensed items Not dispensed items need to be endorsed as ‘ND’ and the product needs to be crossed through Mefenamic acid would be reimbursed by NHS If the patient is not exempt a patient charge is also deducted resulting in a loss of £8.40 to the contractor Mefenamic acid 500mg tabs 1OD 28 tabs ND Digoxin 125mcg tabs 1OD 28 tabs ND Items that are not dispensed need to be crossed out with a horizontal line - not a vertical line Otherwise the ICR scanner would be able to read the product and the item would be paid (and a patient charge deducted if the prescription is not for an exempt patient)

Flavours 4 flavours endorsed but only 1 flavour paid
Mocha x10 Vanilla Banana Forest Fruits 4 flavours endorsed but only 1 flavour paid Prescriber has to specify ‘mixed flavours’ or ‘assorted flavours’ or write each flavour separately Fortisip Compact Liquid Feed Milkshake style 40 x 125ml ACBS For paper prescriptions the phrase "flavours not specified" written on a prescription by the prescriber to indicate mixed or assorted flavours is not acceptable, and only one professional fee would be paid, irrespective of the number of flavours supplied to the patient and endorsed. The correct endorsement by the prescriber is "multiple flavours" or "assorted flavours", but preferably the prescriber should write each individual flavour on the prescription. If a pharmacist has not endorsed any flavours on a prescription calling for assorted/mixed flavours, NHS Prescription Services would refer the prescription back to the pharmacy for endorsement.

If back of Rx not completed then
Endorsement area Obscuring DOB If back of Rx not completed then Rx is switched Atorvastatin 10mg Tabs 1ON 28 Lisinopril 5mg tabs 1OD Amlodipine 5mg Tabs 28 DOB 14/8/31 John chemist 142 johns lane N176RS Only paid for 8 tablets Place in red separator!!! Owing quantity mistaken for quantity dispensed 12/28 Only paid for 8 tablets This is an example of what your prescription should not look like. When you endorse it is imperative that all endorsements are completed in a way that they do not obscure any of the information in the main body of the prescription. Now, if you look at the prescription here, the endorsements have been made in the main body of the prescription. This can have the effect of obscuring details of the: - product - endorsement Both of the above can lead to incorrect reimbursement and if not placed in the red separators, the item will be priced by the ICR and will not be paid correctly It is therefore imperative that all endorsement are ONLY made in the endorsement column and not in the body of the prescription. The pharmacy stamp must not obscure the patients details. If the patient was age exempt, and the back of the prescription was not filled out (because they were age exempt) then the prescription will be switched because the pharmacy stamp is obscuring the date of birth. As this prescription contains three items £25.20 is deducted from the pharmacy even though no patient charges have been taken. Any marks in the main body of the prescription can affect payment – hence these prescriptions should go into a red separator. Ticks for example put there by dispensing staff as a guide to what they have got/dispensed can also cause problems, so ticks etc should not be used For atorvastatin, the contractor has ticked against the quantity and the ICR scanner will simply pick up the number 8 instead of 28 and therefore only 8 tablets will be paid for. Avoid putting any information regarding quantities owing in the endorsement column as these could be interpreted as quantity dispensed. You could record owing information on your PMR system or attach a removable owings slip instead. Information regarding quantities owing to a patient should not be annotated in the endorsement area or on the body of the prescription as this can be mistaken the for quantity dispensed. In Lisinopril example, contractor would only be paid for 12 tablets. In the last example, the signature of the prescriber is obscuring both the quantity and the form . In this example only eight tablets would be paid for if processed automatically by the ICR scanner

Switching: Filling the reverse of a Rx
Part 1 Paid (Part 2 and 3) Exempt (Part 1 and 3) Prescriptions are scanned and processed by the Intelligent Character Recognition (ICR) software. On the back of the prescription the software will read the : Ticked exemptions in Part 1 Paid figure in Part 2 Signature in Part 3 Declaration on the reverse of a prescription must be completed on all occasions except where the patient is aged under 16, or 60 or over and a computer generated date of birth is printed on the prescription. For all other exempt prescriptions, only part 1 and part 3 on the reverse of the prescription needs to be completed For paid prescriptions, only Part 2 and 3 on the reverse of the prescription needs to be completed If switched from: • Exempt to chargeable – a prescription charge is deducted for every item on a prescription that is switched • Chargeable to exempt – no deductions of charges are made for items on a prescription that is switched from chargeable to exempt status Switching occurs for two main reasons: 1. A chargeable prescription is incorrectly filed in the exempt bundle before submission 2. The exemption declaration on the reverse of a prescription is incorrectly completed by the patient or their representative When prescription forms are switched from exempt to paid this means that a prescription charge is deducted for each item on the script. This can have huge consequences for contractors as large amount of money can be lost due to simple mistakes and staff not understanding the importance of correctly filling the reverse of a prescription NHSBSA has advised of the following: Forms which have been ticked to claim exemption but which are not signed will be switched to chargeable Forms which have been signed but have no exemption category ticked will be left in the group they were submitted in. No form is ever switched from exempt to chargeable or from chargeable to exempt unless a member of staff has made the decision to switch it groups based on the information provided on the form Part 2 Part 3

Prescription Switching: Exempt to Paid
Amlodipine 5mg tabs 1OD 28 tabs Ramipril 10mg capsules 1OD 56 tabs Part 1 completed but Part 2 incomplete: signature missing Simvastatin 40mg tabs 1OD 28 tabs 3 charges deducted £8.40 x 3 items = £25.20 An example of switching is shown here where prescription submitted as Exempt but switched to Paid With this prescription, Part 1 has been completed and Part 3 (signature box) is incomplete the prescription is switched from exempt to paid and in this case a total of three prescription charges (£25.20) is deducted from the contractors payments. Check the declarations made on the reverse of every exempt paper prescription (ideally at the time of handing over the medication to the patient) to ensure that: • The correct exemption box in part 1 is clearly marked with a cross or tick; a faint tick or cross may not be easily detected by the prescription scanners or operators • No markings are present in the ‘amount paid’ box in part 2 • A signature is present in part 3; a pharmacy stamp is NOT acceptable as a signature For paid paper prescriptions ensure that: • The correct levy is collected (particularly when there has been a change to prescription charges) • The ‘amount paid’ box in part 2 is completed correctly • A signature is present in part 3. (this is especially important when a patient is signing multiple prescriptions at a time) If evidence is not provided to the staff by the patient ensure that you place an X in “Evidence not Seen” box A pharmacy stamp is NOT acceptable as a signature The choice of ink colour used to complete declarations has no impact on the switching of prescriptions.

To reduce prescription switching
Ensure that all prescriptions are filed correctly in the paid or exempt bundles at the end of the day If possible, double check the exempt prescriptions bundle for misfiled paid prescriptions during end of the month submission If some months show a higher prescription switching rate compared to other months: • Identify the main reason for switching – incorrect filing of paid prescriptions or incomplete exemption declarations? • Does it coincide with particular members of staff responsible for daily dispensing checks or end of month prescriptions filing? • Can it be attributed to locums or new staff? • Identify and address any staff training requirements • Review pharmacy dispensing SOPs to ensure dispensing staff understand the correct processes to follow

Sorting prescriptions
Daily checks Count prescriptions at the end of the day Highlight/mark prescriptions for red separator Double check all exemption declarations Endorse in the left hand margin only Check all endorsements are correct and legible Keep a separate log of expensive items/OOP claims for reconciliation checks Separate prescriptions into correct charge group Ensure date stamps do not obscure the date of birth

submission of prescriptions
Checks to make before submission of prescriptions Follow up any outstanding queries on prescriptions Set up owings reminder for uncollected items Double check daily prescription counts Check final prescription figures twice before entering details onto FP34c Re-check exemption declarations Check red separator items are placed in red separator Remove any invoices, labels, paper clips, pins, post-it notes, tape or staples Pack bundles neatly without using too many elastic bands Send by courier before the 5th of the month

Incontinence products Appliances (catheters, dressings , hosiery)
Part IXB Incontinence products Part IXC Stoma products Part IXA Appliances (catheters, dressings , hosiery) Part IXR Chemical reagents Moving onto appliances, there are four categories in the DT within the appliance section: Part 9A- appliances for example catheters and dressings Part 9B- incontinence products eg Bard leg bags Part 9C-stoma products eg colostomy bags Part 9 R- chemical reagents eg blood glucose test strips

Appliances Check if product is listed in the Appliances Section of the Drug Tariff (Part IXA, IXB, IXC and IXR) If listed= ALLOWED Not listed= NOT ALLOWED Check the appliance is written as listed in the DT with correct product codes to ensure correct payment Cannot claim OOP incurred when obtaining any appliances in Section IXA and IXR If the product has a CE marking on it, it is classified as a device or appliance. For an appliance to be able to be prescribed on the NHS, it must be listed in the appliance section of the DT. If it is listed then it is allowed. If it is not listed then it is not allowed. To check whether or not an appliance is allowed in the drug tariff you can : Check on DM+D Call the NPA If you have the product in store then check if it has a CE mark on the reverse of the box. What you also must consider is if the prescription is written correctly. Especially in the case of hospital and nurse prescriptions, they are usually not written with all the details or the correct product description. The product must be written as it is listed in the DT to ensure correct payment.

Appliances Example 1: Otex Express ear drops (10mL)
CE marked and classed as a medical device Not listed in DT Not allowed Otex ear drops (8mL) Not CE marked Not in the Blacklist Allowed Same ingredients in both products!! Otex ear drops (8ml) are licensed as a pharmacy medicine whereas Otex Express ear drops (10ml) are CE marked which means they are classed as a medical device. However, the composition of both products is exactly the same. Otex ear drops would be allowed on an FP10/WP10 because they are not CE marked and are not in Part XVIIIA (the Blacklist) of the England and Wales Drug Tariff March However, Otex Express ear drops would not be allowed on an FP10/WP10 because they are CE marked and are not listed in the England and Wales Drug Tariff May 2016.

Appliances Example 2: Uro-Tainer sodium chloride 09% catheter maintenance solution AND Uro-Tainer M sodium chloride 0.9% catheter maintenance solution Uro-Tainer sodium chloride 0.9% ALLOWED Uro-Tainer M sodium chloride DISALLOWED as it has a CE marking and is not listed in the appliances section of the Drug Tariff Uro-Tainer NaCl 0.9% catheter maintenance solution is allowed to be prescribed on NHS prescription forms; however, Uro-Tainer M NaCl 0.9% catheter maintenance solution is disallowed on NHS prescriptions. This is because Uro-Tainer M NaCl 0.9% catheter maintenance solution is ‘CE’ marked and is not listed in the appliances section in the relevant Drug Tariffs.

EPS Electronic Prescription Service

EPS Release 2 - Statistics
Latest figures on EPS Release 2 (as of 11May 2016): 98.6% of pharmacies (11,598) EPSR2 enabled 80% of GP practices (6,203 practices) EPSR2 enabled More than 18 million patients have set a nomination More than 255 million prescriptions have been sent

Electronic Repeat Dispensing
Presently need to nominate a dispenser – in future nomination will no longer be necessary Patient consent required – good practice to record RA token not required by pharmacy to dispense Rx Patients can change their nominated dispenser at any point within the electronic repeat dispensing cycle Maximum four items on each EPS RD prescription Any EPS RD items ordered must be mapped on dm+d

Electronic Repeat Dispensing
First issue downloaded like regular EPS R2 prescriptions After first issue is dispensed send DN to Spine Next issue automatically available 7 days before it is due A new timing logic was introduced from 18 February The new timing logic is now linked with the prescriber’s issue date rather than when the DN was sent to the spine Able to manually request subsequent issues early Able to supply 2 or more issues at the same time Confusion over dates – validity and post-dated prescriptions? In order to get the next issue of an electronic repeat dispensing prescription the dispenser must mark every item on the previous issue as either ‘dispensed’ or ‘not dispensed’. After each subsequent issue has been dispensed to the patient the dispensing site must send a dispense notification to the NHS Spine. This should be done once items are handed to the patient, or at least on the same day.. The due date for each issue of an electronic repeat dispensing prescription is now based on the prescribers issue date or an appropriate (previously it was based on when the dispense notification was sent to the spine) minus seven days. If an electronic repeat dispensing prescription has any item ‘owing’ the next issue will not be available until all previous items are set to either ‘dispensed’ or ‘not dispensed’. A patient can obtain subsequent issues of a electronic repeat dispensing prescription early as long as previous items are marked ‘dispensed’ or ‘not dispensed’ if patient requests earlier issue Yes, the pharmacist should use his/her professional judgment to dispense instalments at an appropriate interval, if clinically suitable. From a process perspective, the issues must be pulled down and dispensed in order, so the pharmacy would be required to pull down the first issue, update the Spine to indicate that the issue had been dispensed and then repeat the process with the second issue The original date when the prescription was created and signed, is the only date required for a repeat dispensing prescription, this appears on all dispensing systems. Some dispensing systems will also display or print the date the next issue is expected to be dispensed, based upon the interval set by the prescriber. If the dispensing notification is not sent when the patient collects their electronic repeat dispensing prescription, the next electronic repeat dispensing prescription will show as being post-dated. However, the legally valid date for an electronic repeat dispensing prescription is the date that it was issued and this is the only legal date. Provided that the date on the prescription is within the validity period of 12 months from the date the electronic repeat dispensing prescription was issued, the prescription can be dispensed.

EPS - checking exemption/paid status
Ensure all exemption/paid status is completed unless patient is age exempt and DOB is included on the prescription Some systems automatically default to chargeable status Scripts may be switched to paid if not completed D.O.B. 15/05/1946 For each Electronic Prescription Service (EPS) Release 2 prescription, pharmacy teams must mark whether a prescription charge was made or an exemption category applied, and whether evidence of any exemption was seen The Pricing Authority base payment solely on information contained in the electronic prescription message, therefore it is essential that prescription charge exemption information is recorded accurately in the electronic message to ensure correct payment Unless the patient is age exempt or has paid the prescription charge, the reverse of a prescription or dispensing token needs to be completed and submitted to the Pricing Authority along with the monthly paper prescription bundle Exemption and paid status need to be completed for each EPS script unless the patient is age exempt and the patients DOB is included in the electronic prescription message If the exemption/charge status is not completed on the EPS script and the script is sent to NHSBSA for payment, the script will be switched to paid and a patient charge will be deducted for each item. This is particularly important when there are multiple items on a script. Example: If you had an EPS script for one free-of-charge oral contraceptive and a paid item Pharmacists should enter the prescription as a paid prescription. NHS Prescription Services will automatically process the paid item as ‘paid’ and the free-of-charge contraceptive as ‘no-charge’. dm+d identifies oral contraceptives as having no prescription charge applied to them and so NHS Prescription Services will not deduct a charge. For age exemptions, Remember that exemption status is determined by when the patient declares exemption and not the age then the prescription was issued

Supplementary product information
Prescription medication field Reimbursement based on the ‘Prescription medication field’ Supplementary information included in any other field, for example, dosage instructions, will NOT be taken into account Pricing authority will price for standard formulations instead of preservative free EPS Carmellose 0.5% eye drops 2 drops in both eyes bd Preservative free 10mL Before dispensing a prescription, you should always check if any supplementary product information is written on the prescription other than in the prescription medication field (the first line of the prescription where the item name is). Unlike paper FP10’s where you have the option of placing the prescription in the red separators for manual pricing, with EPS scripts, unless the supplementary product information is contained in the prescription medication field, then it will NOT BE TAKEN INTO ACCOUNT for reimbursement purposes. You will need to return the script back to the spine and ask the prescriber to either : Cancel this prescription and generate a new EPSR2 prescription for the correct product To issue a regular FP10 prescription Payment is paid based on the product field – no supplementary information should be put into the dosage field as this is not seen

When to claim for EPS scripts? Dispense Notification sent
Send Dispense notification (DN) message first Claim notification message within 180 days of DN Owings – expire after 180 days Dispense Notification sent Claim message sent Payment for 28th April 4th May April 30th April 6th May May 1st May 5th May When a prescription is dispensed and the prescription is being submitted for pricing electronically, there are two messages that should be sent to the Spine, ‘a dispense notification message’ and a ‘claim notification message’ A dispense notification should only be sent once the medication has been dispensed and collected by the patient. A claim message which includes endorsement information and information on the charge status of the prescription can be sent at the same time as the DN message or separately at a later date When a dispense notification has been sent in a given month the electronic claim message must be received by NHS Prescription Services before midnight on the 5th of the following month to secure payment with that month’s submission. The table above provides examples of when payment will be received All electronic claim messages must be sent within 180 days of the dispense notification message being sent (the ‘claim reconciliation period Schedule 4 CDs can be dispensed no later than 28 days after the appropriate date on the prescription .The prescription will expire after 28 days and any subsequent re-imbursement claims will be rejected

EPS - Owings All items must be marked as fully dispensed or not dispensed before claiming A prescription marked as partially-dispensed or owing will have its status changed to ‘expired’ 6 months after the last dispensing event (when DN is sent) After expiry an electronic reimbursement claim to the NHSBSA cannot be processed. Claim for what was dispensed rather than allowing a prescription to reach its expiry because it was part-dispensed Does your system supplier issue alerts or warnings before prescriptions are about to expire? Owings Where you have an owing you cannot submit your claim until it is complete. The electronic claim message can only be sent once the dispense notification message has been sent for that electronic prescription. Remember to regularly monitor your owings because after 180 days the Spine will remove the prescription and you will be unable to claim Where you have dispensed one item but only part of a second item, and the patient has confirmed that they do not wish the remainder to be dispensed, you may choose to mark this item as fully dispensed with the actual quantity supplied. If none of the second item has been dispensed then this should be marked as not dispensed and the prescription should be submitted. Remember not to let the prescription reach its expiry System suppliers have flexibility to introduce or improve the warnings and reports to alert pharmacies that prescriptions have gone unclaimed. The system supplier should warn you by highlighting or by reporting those prescriptions that are nearing the 180 day expiry

Sending DN and claim messages
Check exemption status and endorsement prior to sending claim notification message Send claims throughout the month and claim on time, before midnight on the 5th of following month Claim before prescription expiry; within 180 days (6 months) of sending DN Ensure partially dispensed scripts are claimed before they expire CDs completed within 28 days of appropriate date The Pricing Authority only begin pricing electronic prescriptions once they have received the end-of-month submission form (FP34C). This form covers both paper and electronic prescriptions and is submitted together with the paper prescriptions dispensed in the month concerned.

Amending a claim From August 2014, system suppliers can introduce a ‘claim amend functionality’ Ability to correct a claim accidentally submitted as paid instead of exempt or vice versa Offers ability to add/remove dispenser endorsements or amend a quantity Without this facility the electronic reimbursement claim message cannot be changed Possible as long as it is done within the reimbursement period – before the end of the 5th day of the month after it was dispensed From August 2014, suppliers can introduce functionality so that prescriptions can be amended before the pricing agency ‘locks’ them for pricing It may be possible to make a change e.g. amending an endorsement or changing a pt’s exemption after the claim message has been sent. However this is only if your system supplier has a system in place to allow you to do this It is submitted Before the end of the 5th day of the month after it was dispensed (DN sent)

EPS tokens Dispensing tokens are issued by the dispenser/pharmacy
White FP10DT Prescription tokens are issued by the GP/surgery Green FP10SS Dispensing tokens called an 'FP10DT' is white in colour and is generated by a dispenser. It will be printed with the annotation ‘dispensing token’. In EPS R2, these may be presented at a pharmacy where a patient has nominated a pharmacy but their nominated pharmacy has been unable to dispense the prescription. This is not a legal prescription but the barcode on the form can be used to ‘pull down’ the legal NHS electronic prescription from the Spine. NHS England teams are responsible for supplying community pharmacies with blank FP10DTs for printing dispensing tokens. Prescription tokens (issued in parallel with a legal electronic NHS prescription) The green FP10SS form may be used by the prescriber to print a prescription token. The right hand side of the token will include a note that the electronic prescription message has been sent to the nominated dispensing site along with the name and address of the site.

EPS Tokens At the end of each month send all dispensing tokens to the pricing authority where: An exemption declaration is captured (other than age related) A patient charge is paid Tokens are used for audit purposes only Tokens are not used for pricing – no endorsing Payment is solely based on the information contained in the electronic claim messages Which EPS tokens are submitted? * Where a prescription token or a dispensing token has been used to record a signature for a non-age related exemption, or the patient (or their representative) has signed the token and paid for the items these must be submitted in the same month that the electronic claim was submitted, together with the FP34C submission document * The tokens do not need to be sorted, although they must be bundled separately from the paper FP10 prescriptions — this is because submission of tokens is for audit purposes only; they are not processed for payment

EPS - Tokens Ensure you have plenty of dispensing token stationery
available so you don’t run out Do not print tokens on plain white paper No need to sort tokens into paid/exempt or by doctor Tick ‘ETP token for non-payment’ box on FP34C Bundle tokens separately from main prescription bundle Do NOT place tokens in red separator or with FP10 bundle Make sure that pharmacy has ordered sufficient FP10DT forms, ink/toner cartridges to print out tokens. Patient or Patient representative signatures must be captured in Part 3 on the reverse of dispensing tokens (FP10DT) or prescribing tokens (if the patient is given one by the GP practice) for prescription charge payment/exemption purpose When you submit them there is no need to sort them into prescriber order nor do you need to separate the red separator scripts out. Submit all ‘non-age exempt’ and chargeable EPS Release 2 tokens (prescribing and dispensing) as one separate bundle securely tied with elastic bands or string with your batch for the same month that the claim was submitted. Tokens must be submitted as a separate secure bundle. If you submit an EPS token as part of your FP10 batch of paper prescriptions for processing and reimbursement, it will be disallowed and an image of the token will be returned to you marked ‘DA20 -

EPS tracker Did you know that you can track the status of a electronic prescription using the EPS tracker Tracks journey of prescription from prescribing to dispensing Search by prescription ID (located on the dispensing/prescription token), NHS number or date range Requires PC and Smartcard The tracker will confirm if the prescription has left the prescribing site, reached the Spine or if it has been delivered to an alternative dispensing site. The application is designed to be used when there is a legitimate need to verify that a prescription exists or to identify a prescription status during the prescribing and dispensing process, e.g. which dispenser has downloaded it, when was it dispensed or has it been claimed. If a patient came into the pharmacy wishing to pick up their medication, and the EPS script had not arrived to your pharmacy then the EPS tracker could be used to locate the RX and provide the status of the prescription. It may be that the prescription has been received by another chemist in which case you would need to direct the patient to that pharmacy or ask the pharmacy to release it back to the spine so you can retrieve it.

Summary: EPS R2 prescriptions
Download prescriptions regularly throughout the day Check correct exemption/charge status is recorded Send DNs once endorsements are double checked Send all DN’s at the end of day Claim for partially dispensed scripts before they expire Discuss with system supplier about expiry warnings Discuss with system supplier about recalling scripts Our top tips include: This will give you an opportunity to prepare the prescription in advance of the patient’s arrival and order out of stock items where required. This will mean you’ll be more likely to be able to dispense the items in full when the patient arrives to collect them Whenever an EPS script is dispensed, ensure patients exemption declaration or charge status is annotated on the pharmacy system. This prevent prescriptions being sent without completing all necessary information. If not done correctly some systems These scripts will be switched to paid Only send DN;s once endorsement and exemptions have been double checked-some contractors may only wish their regular pharmacist to send claim messages to prevent switching Send all DN’s at the end of the day they have been dispensed. That way, exemptions and endorsement can be checked at one go before sending claims. Discuss with your system supplier about adding a functionality onto your system to allow you to recall scripts after they have been claimed for Always claim for partially dispensed scripts before they expire. It is better to claim for some then to claim for none! Discuss with your system supplier about adding warning pop up’s when prescriptions are about to expire. This prevents scripts from being left unclaimed • Ensure all information regarding patient exemption/prescription charge status is correctly recorded before sending the dispense notification and claim. • NHS Prescription Services only make payments to contractors based on the information contained in the electronic prescription message For assorted flavour drinks the AF box should be ticked to get paid the appropriate fees Owed items issues Some systems do not allow pharmacies to dispense owed items for non-controlled drugs (CDs) where there is also a Schedule 4 CD present on the electronic prescription. This is because the system is calculating the validity of the prescription as a whole, rather than individual items. HSCIC is aware of the issue and is taking steps with system suppliers to prevent the problem occurring. In the mean time, the prescriber should be contacted and separate prescriptions requested.

Background Transparency – how do you know your prescription bundle has been accurately priced? Schedule of Payment (FP34) data difficult to analyse without adequate resources Contractors not always well informed about prescription reimbursement Schedule of Payment data is quite difficult to analyse without adequate resources. Understanding the FP34 data will help contractors achieve optimum business performance by: reviewing SOP’s and practices within the pharmacy e.g. with endorsing comparing the pharmacies performance against others Monitoring the pharmacies success using trend analysis Many of the KPI’s are affected by poor endorsing, improper claiming of scripts and prescription submission mistakes. Therefore understanding where and why these problems occur can help a business review and change policies within the pharmacy to ensure that these mistakes are corrected.

What is Check34? Secure web-based service launched by NPA in 2015
A powerful tool to help manage prescription business Month by month performance data for 14 KPIs Turns raw data into useful information Graphical and tabular presentation of FP34 data Explanatory text to help interpret each KPI Troubleshooting algorithm to identify/resolve any anomalies Check34 is an online system which analyses pharmacies’ FP34 data so that contractors can identify trends and anomalies in prescription payments, and track key performance indicators. It helps achieve optimum business performance, because you can assess your own performance data and compare against other pharmacy businesses. The National Pharmacy Association (NPA) and the Pharmaceutical Services Negotiating Committee (PSNC) have come together to provide a solution for independent pharmacies who wish to assess their prescription business performance and reassure themselves that they are being accurately remunerated by the NHS. The NPA has obtained the exclusive right to make PSNC’s new ‘Check34’ service available to independent community pharmacies in England. Check34 analyses pharmacies’ FP34 data so that contractors can identify trends and anomalies in prescription payments, and track key performance indicators, which will enable them to better manage and understand their NHS payments. Check34 is an online prescription information system which presents and analyses 14 key performance indicators from the monthly FP34 Schedule of Payment report that all contractors receive so that they can: • Monitor NHS payments and troubleshoot potential problem areas • Compare their performance with other pharmacies at local and national level • Identify lost revenue from prescription switches and under-claiming staff hours • Monitor MUR and NMS performance • Reconcile their FP34c declaration with the subsequent FP34 payment • Review up to 24 months historical data • Download data from all sections of the FP34 for business reporting and accounting purposes

Benefits of Check34 Enables you to benchmark your pharmacy
Pharmacy performance for each KPI compared against: National averages Other pharmacies in your area Other branches within your company Can be used at head office & branch level Provides up to 24 months history It turns raw data into useful information and allows contractors to visually monitor their business performance through graphical and tabular representation. Check34 provides this data analysis, which has until now has generally been available only to larger companies with substantial IT resources. Check34 can be used by pharmacy companies of any size. It has the advantage of being able to be used either at both head office and at branch level. Each organisation will need to appoint a Check34 manager. This person will be responsible for setting up and managing access to Check34 for their organisation. The Check34 manager is able to restrict access to Check34 by KPIs to specific users eg area managers, superintendent pharmacists or individual branch manager or pharmacists. The system will show you month by month performance data for 14 KPI’s with up to 24 months history .

14 Key performance indicators (KPIs)
Items dispensed per month Average item value Fees and drug costs Working hours (for correct Practice Payment) Script switches + fees lost Expensive items (value, number, % of total account) Zero discount (value, number, % of total account) MURs completed per month and YTD NMS completed per month and YTD Advance vs Paid payment Advance no. of items vs Actual no. of items paid FP34 EPS Vs paper items Script source analysis Flu vaccinations The NPA have identified 4 KPI quick wins: NMS, MUR, Switching, and Expensive Items. These have been identified as the four top KPIs to help pharmacies get more money in their pockets, grow business and see results the quickest.

Home page A menu of activity options is on the left
A drop down menu top right gives access to your profile and an contact form Your company and its pharmacies can be viewed in the blue panel top left - more on this later The red, orange and green panels across the top carry information from the latest financial period on: the amount lost through script switching – alternates between the month chosen and the year to date MUR fees earned and performance – alternates between the month chosen and the year to date The number of NMS consultations carried out – alternates between the month chosen and the year to date The main panel in the centre lists the 14 KPIs and a traffic light system – red, amber green – indicates whether pharmacy performance is ‘on trend’ or outside expected confidence limits. Best and worst performers for the KPI selected are given in the two panels on the right. The screen will default to the current financial period but you can select different periods using the month/year selectors in the grey bar above the KPI list.

Example KPI 1 – Number of items “Nearest 10” parameter chosen
Trend line going up “Nearest 10” parameter chosen This graph shows the results for Number of Items. Explanatory text appears below each KPI. Comparators, where they are appropriate can be clicked on and off using buttons top right. The ‘Nearest 10’ is selected in this example. How does your pharmacy compete against the national average of items overall? Does your pharmacy trend follow the same pattern as the national trend? Unexplained variations in the national average vs. the individual pharmacy may be due to local circumstances. Explanatory text

Example KPI 7 – Switching
Contractors not always well informed about prescription reimbursement. What Check34 does is that it gives contractors Month by month performance data for 11 KPIs with Explanatory text to help interpret each KPI and a Troubleshooting algorithm to help identify and resolve any reimbursement anomalies. E.g. if a contractor noticed that in one month there were an increased level of prescription switches, they could try and identify the possible reasons for this e.g. incorrect filing of prescriptions during submission or declarations not being signed correctly. This is where knowing your drug tariff is so important because it addresses such issues . This pharmacy has lost over £1500 in lost fees in the past 12 months. Is switching a problem for your pharmacy? How does your pharmacy compete against the national switching rate? Are there particular months with worse switching rates than others? Can this be attributed to other factors such as locums, new members of staff? What is the main reason for your switches? Incorrect filing of paid prescriptions or unsigned prescriptions?

Example of KPI 8 – MURs How many MURs has the pharmacy completed over the last 12 months? How does this compare to the national average?

Mind map – Number of items (KPI 1)
The NPA has produced detailed mind maps for each KPI to help contractors/staff understand the background to each KPI. By looking at your graph for number of items and the trend patterns, you can identify any anomalies in certain months. Using the mind maps for Number of items, you can explore the possible reasons for irregular patterns. These diagrams are produced for each KPI so contractors can try and identify reasons for any anomalies and identify ways of correcting them.

REMINDER Sign up for Check 34 by logging on to www.npa.co.uk
For help and advice on Check34 or any other questions relating to the Drug Tariff, NPA members can contact the Pharmacy Services team via telephone on or via For more information, please visit our website. You can also find the registration forms and if you’ve already registered and have access to check 34, you can view our Check 34 resources.

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