Reimbursement Limits on GMS/GMR/LTI/DPS | ICPhA

Reimbursement Limits on GMS/GMR/LTI/DPS

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As part of spending cuts and reviews HSE PCRS have introduced a number of reimbursement limits on high cost items and/or items with somewhat unclear daily/weekly/monthly dosages.

Below is a list of some of these items based on anecdotal evidence and PCRS comment. PCRS can sometimes be sneaky when it comes to these items and they will not always reject the payment outright, just reduce the amount they pay you, therefore you will need to check you claims very carefully to spot them. Given the high cost of a lot of these items, carefully checking your payments is strongly advised.

Item Anecdotal evidence PCRS Comment Notes
Calogen 500mL 6 bottles 15 bottles* *200mL & 500mL sizes
Nutramigen baby foods 10 tins Nutramigen 1 (10 tins), Nutramigen 2 (depends on patient need**) **2-3 per week and monitor
Neocate LCP 400g 12 tins 12 tins  
Nutrison 42 units 1L, 500mL size (depends on patient needs) Shelf life after opening is 24 hours
Oral nutritional supplements 1 month (Single GMS scripts only. Quantities of greater than two daily may be queried and invoices requested. Prescribers advised that first script should be for 14 days, but this doesn't seem to to be a rule for payments. Further clarification welcome.) Based on individual needs – if a quantity is high, it will be rejected and additional evidence will be required such as copy of Rx and invoice to secure payment.  
Instant Carobel 10 packs per month 14 packs per month as a guideline, but can be adjusted to individual needs.  
Pro-Cal 6 per month, someone got paid for 18 120mL often claimed as larger size of 250mL triggering a reject, limit is 12-15 for 120mL  
Thick & Easy 8 tins For 225g limit is 6 tins as a guideline, but not strict.  
Adrenaline pens 3 pens 6 pens  
Nicotine replacement therapy 14 days on initial script, 28 days on subsequent scripts (will try to get definitive quantities for gum, lozenges and inhalers). Single GMS scripts only. Not on DPS. not checked with PCRS  

 

From the conversation with PCRS, it would appear that due to the high cost and unclear dosage of oral nutritional supplements and some infant formulas the PCRS operate a system of guideline quantities and manual checks. If the quantity is deemed high (i.e. above the generic guidelines) it is checked against that patient's history and can be increased on an individual basis following submission of Rxs and invoices from the pharmacy.

 

Also keep in mind the following:

  • You cannot make different claims for 2 different flavours of same Nutritional product.
  • If your GP prescribes nutritional supplements with the same GMS number then you can only claim for one. (add the 2 together)
  • Local approval does not imply PCRS approval.
  • Dressings with 77*** code are allowed on DPS but not on any other scheme including stock orders.
  • Only dispense PKU products once per day. A second dispensing on the same day will not be paid. Sometimes a second dispensing in a month may not be paid in the case of XP Maximum. PKU Coolers seem to be OK in that regard.
  • In relation to NRT scripts. Do not claim for two dispensings in a month. eg 14 days and 28 days. only the 14 days will be paid not matter which part of month they were dispensed in.
  • Only dispense any item once per day. A second dispensing for the same item will be seen as a duplicate claim and will not be paid (i.e. different flavours with the same GMS code or before & after doctor or dentist appointment / emergency supplies). Be particularly careful with the DPS scheme where some items might be rejected if claimed twice in a month!
  • BMX GMS =99159
  • BMX DPS = 99168

Examples above were reported on poitigeir.com

See also:

 

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