Submitting ODB Claims Over $9,999.99

The CPhA3 claim standard does not support drug costs exceeding $9,999.99. In order to submit online prescriptions to Ontario Drug Benefit (including Trillium) for $10,000 and above, the prescription must be split into multiple claims. In order for the Health Network System to adjudicate the claims appropriately, pharmacists are required to submit the claims according to the following rules:

  • The quantity supplied must be split into approximately equal portions without any changes to the submitted price per unit (each split claim with drug costs less than $10,000);
  • The day’s supply must be split accordingly (please note Drug Utilization Review (DUR) responses such as refill too soon and duration of therapy messages would be based on this reduced day’s supply);
  • Mark-up remains at 6% on all split claims; and,
  • A dispensing fee must be submitted for the first split claim only.

For the following instances, a manual paper claim is still required:

  • Extemporaneous compounds with a drug cost of $10,000 or more;
  • More than two (2) intervention/exception codes are required for submission;
  • Quantity supplied cannot be split into multiple online submissions (i.e., quantity is 1);
  • Each unit of drug (i.e., 1 tablet) costs $10,000 or more.

How do I submit a claim over $9,999.99 to ODB?

  1. Determine the # of claims required to submit the Rx, as the quantity must be split into approximately equal portions. For example, a prescription for 100 tablets (drug cost of $12,000) should be split into 2 online claims for 50 tablets each (drug cost of $6,000 for each split claim).
  2. Open the incomplete prescription in Rx Detail with the full dispensing fee and 6% markup.
  3. Select the Third Party tab.
  4. Select the Add button and add the following intervention code:
    • MP: Valid Claim - Value $1,000.00 to $9,999.99
  5. Select the Fill button.
  6. Highlight the completed prescription from the Workbench and select the Refill button.
  7. Select the magnifying glass icon. The "Pricing Details" window opens.
  8. Change the dispensing fee to $0.00 and leave the markup as 6%.
  9. Select the Third Party tab.
  10. Select the Add button and add the following intervention codes:
    • MP: Valid Claim - Value $1,000.00 to $9,999.99
    • MM: Replacement Claim, Drug Cost Only
  11. Select the Fill button.
  12. If the Rx is being split into more than 2 claims, repeat steps 6-11 until all claims are submitted.

For the example provided above, a prescription for 100 tablets (drug cost of $12,000), your split claims will appear as follows:

Note: Supporting documentation may be requested for post-payment verification. Standard documentation retention requirements apply. The prescription, wholesale invoices, and other relevant documents must be kept on file for a period of 24 months in a readily retrievable location for audit purposes.