Quebec Legislative Requirements

All mandatory requirements that are driven from new legislation are considered to be top priority. Implementers must address these requirements as soon as possible and this new data must be part of the initial implementation MVP phase of PCS FHIR.

Overview

Following is a excerpt of a document pertaining to "Updating the Pharmacy Claim Standard" that was issued by AQPP on December 20, 2023. This document clearly outlines new legislative requirements that are addressed in the PCS FHIR standard.

Background - About the AQPP

Created in 1970, the Association Québécoise des pharmaciens propriétaires (AQPP) 's mission is to study, protect, defend, and develop its members' economic, social, legal, and professional interests and of community pharmacy in Quebec. The defence of property rights and professional independence is at the heart of our mission. Today, the AQPP brings together more than 2,000 pharmacists who own nearly 1,900 pharmacies in Quebec.

Explanation / Further Context

In 2017, the Minister of Health and Social Services of Quebec enacted legislation requiring pharmacists to submit a detailed receipt when a medication covered under the basic prescription drug insurance plan is sold. Specifically, the ruling states that: 8.1.1. A pharmacist must give an itemized invoice to a person from whom payment of a pharmaceutical service, except a service for which no contribution is payable under subparagraph 1.4 of the first paragraph of section 78, or of a medication or supply covered by the basic plan is claimed. The invoice must list separately the pharmacist's professional fees for every service provided, the price paid by the basic plan for every medication or supply provided and the wholesaler's profit margin, if any. [...] In May 2021, the Court of Appeal of Quebec confirmed that the expression "person from whom payment of a pharmaceutical service" is not limited solely to a person covered by the private sector but also to the private insurer to which the pharmacist claim payment of a pharmaceutical service provided. This judgement confirms that a pharmacist must therefore provide the itemized invoice to such a third-party payer. In summary, a pharmacist must therefore give an itemized invoice which must list separately the pharmacist's professional fees for every service provided, the price paid by the basic plan or supply provided and the wholesaler's profit margin, if any. This obligation only applies to the medicines included in the basic prescription drug insurance plan.

The Requirements

Giving an itemized invoice to a third-party payer when the claim is processed in real-time at the pharmacy is not a task easily accomplished by a pharmacist. Various options have been explored, but one option would probably be the easiest way to provide compliance. This option implies using the efficient online processing of prescription drug claims already in place with the Pharmacy Claim Standard (PCS) created by the CPhA. PCS is universally adopted in pharmacies and by private third-party payers in Quebec. The actual fields do not allow the submission of the items required by the law in a way that fully complies with the PCS. The pharmacists of Quebec represented by the AQPP requests that new fields are added when the PCS is updated to allow the pharmacists to submit the specific items.

Fields to be Supported

The AQPP identified four fields that would need to be updated or added to allow complete compliance with the regulation. The labels of these fields are open for discussion, but the information included will represent the needs expressed explicitly in the following section.

1. Professional fees
   This field already exists under D.68.03. But, in Quebec, the definition would need to be updated to reflect that the professional fees also include any cost upcharge at the pharmacy level. The field could be kept with the corrected description or be modified to have six (6) positions in length to give more freedom if expensive medications come in the following years.
   
   
2. Price paid by the basic plan/Guaranteed Selling Price
   The price paid by the basic plan is shown on the list of medications. This list shows the guaranteed selling price. The guaranteed selling price does not include the wholesaler's profit margin. Therefore, it is essential to note that this is not the Drug Cost/Product Value in field D.66.03 since it is not the total value or drug/cost price to the provider from which the pharmacy obtains the product. The new field would require having seven (7) positions in length to account for drug costs up to $99999.99. If possible, we could have explored the possibility of going up to eight positions. This field would be mandatory for medications included in the basic prescription drug insurance plan.
   
   
3. Wholesaler's profit margin
   The wholesaler's profit margin would include only the wholesaler's profit margin, which is currently at 6,5%, with a cap at $49 for the medications included in the basic prescription drug insurance plan. This field could be mandatory, and a length of five (5) decimal positions would be enough for current and future needs. If the pharmacists purchased the medication directly from the manufacturer, there would not be any wholesaler's profit margin. Therefore, the positions would only be "zeroes."
   
   
4. Total drug cost
   The total drug cost should be the only price field submitted to the third-party payer for medications and services that do not fall under the basic prescription drug insurance plan. This total drug cost would include the acquisition cost from the supplier and the professional fees from the pharmacist. These fees would consist of any cost upcharge added at the pharmacy level. Again, this field should be decimals with seven (7) or eight (8) positions in length. For medications that fall under the basic prescription drug insurance plan, this field would be the sum of the previous three.
   

Scenario Overview

The following details various scenarios and how the new fields and existing CPHA3 fields are populated.

Message	Scenario	Quebec Proff Fee	Proff Fee	Drug Cost	Cost Upcharge	Guaranteed Selling Price	Wholesaler's Profit Margin	Total DrugCost Submitted
CPHA3	Quebec Claims - Qualifing and Excluded Claims	Yes	Yes - Includes Upcharge	Yes - includes Wholesaler's Profit Margin & Guaranteed Selling Price	No	No	Yes	Yes
FHIR	Quebec Qualifing Claims	Yes (Mandatory)	No	No	No	Yes (Mandatory)	Yes (Mandatory)	Yes - Quebec Proff fee + Wholesaler’s profit margin + Selling price guaranteed
FHIR	Quebec Excluded Claims	No	Yes	Yes	No	No	No	Yes - Quebec Proff fee + Wholesaler’s profit margin + Selling price guaranteed
FHIR	Claims Outside of Quebec	No	Yes	Yes	Yes	No	No	Yes - Proff Fee + Drug Cost+Cost Upcharge
FHIR	Quebec Exceptions - TBD