Special containers and antibiotics requiring reconstitution
Special containers and antibiotics requiring reconstitution
There are special requirements and reimbursement arrangements for dispensing those products which are recognised as being packaged in special containers or items requiring reconstitution.
What is a 'special container'?
Part II Clause 10A of the Drug Tariff sets out the rules for the quantity to be supplied of a prescribed product. Under the normal rules, pharmacy contractors are reimbursed for supplying the exact quantity ordered by the prescriber, this is unless the preparation has been recognised as being packaged in a special container.
PSNC has a special container database which contains information about all the products which have special container status or sub-pack as a special container. Special containers listed in the Drug Tariff are marked with a small black square next to the drug name, for example:
A medicinal product is granted special container status in cases where it is not practical to split an original pack, for example where the product is sterile or hygroscopic. A pack can be granted special container status if the medicine or chemical reagent is:
2. Effervescent or hygroscopic
3. a. A liquid preparations for addition to bath water
b. A Coal Tar preparation
c. A viscous external preparation
4. Or packed in a castor, collapsible tube, drop-bottle, pressurised aerosol, puffer pack, roll-on-bottle, sachet, shaker, spray, squeeze pack, container with an integral means of application or any other container form which it is not practical to dispense the exact quantity.
The manufacturer of the product must provide evidence of its eligibility and no products are automatically granted special container status.
If there is a particular pack that does not currently have special container status and it meets these criteria, pharmacy contractors can contact the PSNC Dispensing and Supply Team (0203 1220 810 or email@example.com) we can liaise with the manufacturer and make a request to the NHS Business Services Authority (NHSBSA) for a change in the pack’s status where appropriate.
Reconstitution of certain oral liquids - the dispensing of oral liquid antibiotics
Part II, Clause 13 of the Drug Tariff (reconstitution of certain oral liquids) states:
When the quantity reconstituted from an original pack or packs is unavoidably greater than the quantity ordered and it has not been possible for the contractor to use the remainder for or towards supplying against another prescription, payment will be calculated from the Basic Price of the preparation and will be based on the nearest pack or number of packs necessary to cover* the quantity ordered.
* The phrase “necessary to cover” is interpreted as the amount dispensed must allow the patient to complete the full course of medication prescribed.
Item requiring reconstitution listed in the Drug Tariff are marked with a small black circle next to the drug name, for example:
The following products are considered under the rules in Part II Clause 13: oral antibacterial, antiviral or antifungal products listed in BNF sections 5.1, 5.2 and 5.3 (except 5.3.1). These medicines are marked in the Drug Tariff with a small black circle next to the drug name or can be found by typing the product name into PSNC’s special container database and will be categorised as an “item requiring reconstitution”.
Where the quantity ordered by the prescriber does not coincide with that of an original pack (or sub-pack when the special container status is placed on the sub-pack) and the product is considered a special container, contractors are required to supply the special container or combination of containers nearest to the quantity ordered and endorse the prescription form with the number and size of these containers. Where the quantity ordered falls exactly between two containers, the contractor should round down the quantity dispensed to the nearest complete container.
The exception to this rule is where the quantity of a drug preparation reconstituted from granules or powder, for example a liquid antibiotic, which is unavoidably greater than the quantity ordered and it is not possible for the contractor to use the remainder of the reconstituted product to fill another prescription. Dispensing in this scenario should be enough packs necessary to cover the quantity ordered.
Note: In a small number of cases there may be an over-riding clinical requirement to dispense the exact quantity ordered rather than the nearest pack, for example if there is a risk that the patient may misuse the medication or if the medicine is required to be packaged into a weekly compliance aid.
Contractors are required to endorse the prescription form with the containers used to dispense from (and the quantity prescribed if it differs due to clinical need). With regards to items requiring reconstitution, no extra endorsements are required other than the usual requirement to endorse the pack size used. The rules for reconstitution are applied automatically to the eligible products.
In calculating reimbursement, the special container rules are automatically applied and contractors will be reimbursed for the nearest pack or combination of packs. With regards to items requiring reconstitution, payment will be based on the nearest pack or number of packs necessary to cover the quantity ordered.
Sorting and submission
There are no specific requirements for sorting these prescriptions separately (unless the prescription meets one of the criteria for inclusion in the red separator).
Q. I have received an FP10 prescription for “Tacrolimus (Prograf) 5mg capsules 36 capsules”, how many capsules should I dispense?
Prograf 5mg capsules are available in boxes of 50 which are recognised as having special container status. In cases where the prescriber orders a quantity which does not coincide with an original pack and the product has been classed as a special container, the pharmacist should supply a special container or combination of special containers nearest to the quantity ordered (i.e. in the above scenario, 1 box of 50 capsules should be supplied).
Q. I have received a prescription for “Ibuprofen 10% gel 30g” but only the 100g pack size of this product is listed in Part VIIIA. How much should I dispense and how much will I be reimbursed?
Part VIII of the Drug Tariff contains the basic NHS reimbursement prices for products prescribed generically. Where an item is in Part VIII, contractors are reimbursed based on the Part VIII price.
In this example, only one pack size is listed in the Tariff (100g pack). As this pack is classed as a special container, a pharmacy would be reimbursed, based on the Drug Tariff price, to the nearest number of 100g packs to the quantity ordered. For example if 30g is ordered, the pharmacy will be reimbursed for a 100g pack, if 120g is ordered, the pharmacy will be reimbursed for a 100g pack.
From a legal perspective, contractors should “supply the special container or containers nearest to that ordered”. Ibuprofen 10% gel is available in a variety of pack sizes including 30g packs. Therefore, in this example, even though the contractor may be reimbursed for dispensing the 100g pack, the contractor should supply 30g as requested. To prevent any allegation of fraud, PSNC recommends that the prescription is clearly endorsed with the dispensed pack size.
Q. I have received a prescription for “Amorolfine 5% medicated nail lacquer 3ml”, what should I dispense and how much will I be reimbursed?
Amorolfine 5% medicated nail lacquer is listed in the Drug Tariff therefore payment is based on the Part VIIIA price for this product. As there is only one pack size currently listed in Part VIIIA and because this particular pack size is recognised as a special container, a contractor will be reimbursed at the Drug Tariff price for 5ml Amorolfine 5% medicated nail lacquer.
There are several products available which match the generic description. For example Loceryl which is available in a 5ml & 2.5ml pack size, Curanail which is available in a 3ml pack, and Omicur which is available as a 2.5ml & 2 x 2.5ml pack. All packs are recognised by the Department of Health and Social Care as special containers. Contractors should ‘supply the special container or containers nearest to that ordered’. Therefore even though the contractor will be reimbursed for dispensing the 5ml pack on this occasion (as per Drug Tariff rules), the contractor should supply the 3ml pack as requested, since this is nearest to that ordered. To prevent any allegation of fraud, PSNC recommends that the prescription is clearly endorsed with the dispensed pack size.
Q. I have received an FP10 prescription for “Erythromycin 40mg/ml / Zinc acetate 12mg/ml lotion 90ml”. This product has special container status. I have dispensed three packs of 30ml. Is it okay to just endorse “90ml” on the prescription?
An unqualified number in the endorsement column could be misinterpreted by the NHSBSA, for example if “90ml” is endorsed, the NHSBSA may interpret this as the pack size used and reimbursement could be based on the price of one pack of 90ml rather than 3 packs of 30ml resulting in financial loss to the pharmacy contractor. The recommended endorsement format in this scenario is “amount dispensed/pack size used” (e.g. “90ml/30ml”).
Q. I have received an FP10 prescription for “Amoxicillin 125mg/5ml oral suspension 140ml”. What quantity will I be reimbursed for dispensing?
The pharmacy would be reimbursed for dispensing 2 x 100ml.
There is an antibiotic rule which means that where the quantity of a drug preparation reconstituted from granules or powder is unavoidably greater than the quantity ordered and it is not possible for the contractor to use the remainder of the reconstituted product to fill another prescription, payment will be based on the nearest pack or number of packs necessary to cover the quantity ordered. This is outlined in full in the Drug Tariff, Part II, Clause 13B.
Under this rule, in the situation described above where the quantity ordered falls between two packs (the Drug Tariff listing is for a 100ml pack size), the contractor can round up to dispense the nearest complete container as it is important for patients on antibiotics to cover the complete course of treatment prescribed. Reimbursement for dispensing two packs will be automatic under these rules, but, as is usual with Part VIIIA products, it is good practice to endorse the prescription and declare the total amount dispensed over the pack size used.
Q. If a drug requires reconstitution which will result in limited stability, how do I get paid?
Part II Clause 13 (Reconstitution of Certain Oral Liquids) covers all prescriptions for oral liquid antibiotics, antifungals and antivirals, which require reconstitution. These specifically relate to antibiotics, antivirals and antifungals listed in sections 5.1, 5.2 and 5.3 (except 5.3.1) of the British National Formulary (BNF). These drugs have been identified as those where it is essential for the patient to receive the full course of treatment.
For products which are not covered by this provision (e.g. Cozaar 2.5mg/ml oral suspension) payment will be as per the normal Drug Tariff rules. Many products which require reconstitution are however considered special containers, and so the contractor should supply the container(s) nearest to the quantity ordered and endorse the prescription form with the number and size of containers. For example, if Cozaar 2.5mg/ml oral suspension x 280ml is ordered, the contractor will be paid for 1x200ml. However, where 340ml is ordered, the contractor will be paid for 2x200ml.
Many of these products are prescribed on a regular or long-term basis, and as such it is advised for contractors to liaise with prescribers to promote prescribing practice which takes into consideration the shelf life of each product.
Q. I have received a prescription for “Phenoxymethylpenicillin 125mg/5ml oral solution sugar free 200ml, 5ml QDS for ten days” but the product only has 7 days’ stability once reconstituted. How will I be paid?
The NHSBSA recognise the total prescribed quantity on a prescription for reimbursement above the calculated quantity from the directions; therefore the pharmacy will be reimbursed for the total prescribed quantity of 200ml in this scenario.
Since only one set of fees can be claimed for this prescription, it may be appropriate for the contractor to discuss the situation with the prescriber and request the possibility of providing a separate prescriptions to recognise the requirement to use more than one bottle owing to the product’s limited stability.
Q. I have a prescription for Premarin 0.625mg tablets, is this a calendar pack?
The calendar pack rules previously allowed dispensing of quantities differing to that prescribed. As this was not in keeping with other legislation such as the Medicines Act 1968, it has been removed.
The removal of the calendar pack provisions ensures that contractors are always dispensing in accordance with the prescriber’s instructions with the exception of special containers and those items considered under Part II, Clause 13 of the Drug Tariff (Reconstitution of Certain Oral Liquids).
Q. I have a prescription for “Voltarol Gel Patch 1% medicated plasters 4 patches”, how will I be paid for this?
This product is available in a pack of 10 with 2 sub-packs of 5 patches. The sub-pack of 5 patches has been granted special container status. In the scenario described, the contractor would be reimbursed for dispensing one sub-pack of 5. This rule is applied automatically but it is best practice for contractors to endorse the prescription form with the packs (or, as in this case, sub-packs) used to dispense from.
Q. I have received an FP10 prescription for “Madopar 25mg/100mg capsules 160 capsules”. The lid of the product contains a desiccant, would I be reimbursed for supplying 2x100 capsules under special container rules?
No. There is a strict criteria, which can be found in Part II Clause 10 of the Drug Tariff, which the Department of Health and Social Care use to determine whether a product should be considered to be packaged in a special container. Although Madopar preparations have integral desiccants in the lid, the manufacturer Roche has not been able to provide any evidence that these products are hygroscopic. Therefore, no Madopar preparations are classed as special containers.
Thus in this example, a contractor would be reimbursed for supplying 160 capsules against a prescription requesting 160 capsules. Broken bulk could be claimed on the residual balance.