The underlying principles for the approval of pharmaceutical treatment for SRCA clients are that the medications:
When requests for medication are denied this is a reviewable decision under S62 of the SRCA. The determination must be in writing to the claimant and must include reasons for the decision as well as a statement that the determination can be reconsidered if the employee or claimant is dissatisfied with the determination. The pharmacy supplying the medication that we are not paying for also need to be advised. If VAPAC has been asked to comment on the case and recommends that treatment be declined their written comments are to be placed on the client's E-file, as well as on their paper file, reflecting that recommendation. A note in Defcare should also be made.
Delegates should be aware that decisions to pay for medical treatment may also be reviewed, albeit not a common occurrence. This may revolve around how much DVA will pay for a service, frequency of service etc. Normal reconsideration practices apply in these circumstances.
The Veterans Affairs Pharmaceuticals Advisory Centre (VAPAC) can assist SRCA and MRCA delegates with medication related enquiries, including appropriate remuneration or negotiation with a pharmacy where a delegate suspects inappropriate pricing, mark ups or dispensing fees are being charged.
VAPAC is able to deem the recovery price of a supplied medicine and calculate an appropriate level of remuneration for a pharmacy based on Pharmaceutical Benefits Scheme (PBS) principles - which are agreed to by the Pharmacy Guild of Australia.
A database that prices all pharmaceuticals does not exist, however, the PBS.gov.au website does list agreed dispensed prices for commonly prescribed medications, but not all medicines including over-the-counter products.
Pharmaceutical claims made by SRCA or MRCA clients must therefore be at the PBS price unless the pharmacy can justify and have the variation approved by VAPAC.
Contact details for the VAPAC Team is via email to VAPAC MRCG Advice or by phone on 1800 552 580.
Links
[1] https://clik.dva.gov.au/user/login?destination=node/20576%23comment-form
[2] https://clik.dva.gov.au/user/login?destination=node/20579%23comment-form
[3] https://clik.dva.gov.au/user/login?destination=node/20561%23comment-form
[4] https://clik.dva.gov.au/user/login?destination=node/20554%23comment-form
[5] https://clik.dva.gov.au/user/login?destination=node/20550%23comment-form