The HSE/PCRS has decided that from the 1st of July 2019 not all Oral Nutritional Supplements which have a PCRS/GMS code will be automatically reimbursed.
The HSE/PCRS has divided the present Oral Nutritional Supplements into two categories namely List A and List B.
If a prescribed product falls under List A, it is seen to be the recommended first-line therapy to be used and will be automatically reimbursed. This arrangement will apply to both new and existing patients and there is no transition period to allow for the switch to happen.
The products in List A are as follows
- Complan Shake 57 G Sachet
- Ensure Shake 57 G Sachet
- Foodlink Complete 57 G Sachet
- Foodlink Complete Sachet (starter pack with shaker) 57 G Sachet
- Foodlink Complete with Fibre 63 G Sachet
- Fresubin Powder Extra 62 G Sachet
- Nutriplete Shake 57 G Sachet
- Nutriplete Shake with Shaker 57 G
Compact/ Mini-drinks Sip Feeds
- Altraplen Compact 125 ml
- Ensure Compact 125 ml
- Fortisip Compact 125 ml
- Fortisip Compact Fibre 125 ml
- Fresubin 2 KCal Fibre Mini Drink 125 ml
- Fresubin 2KCal Mini Drink 125 ml
If a prescribed product is not on the list above (List A) and is on List B and the prescriber believes the patient needs it, then the prescriber or clinician will need to apply using the suitable portal to the HSE for an exemption for the patient.
Either the patient’s GP, HSE dietitians or hospital clinicians may apply on behalf of the patient.
The approval process may take up to 3 working days before approval or non-approval will be communicated back to the GP through the Doctor Application Suite.
This exemption or approval will only be valid for 6 months after which it will be reviewed.
Claims submitted for patients who are not approved for products on List B will not be paid.
However, where a patient is using a product on List B via an enteral feeding tube, PCRS is satisfied to approve in these circumstances. It is important the GP or clinician states this in the application process.
If a prescribed product is on List B then pre-approval is required before reimbursement will be made to the pharmacy.
The following are the products on List B :
- Altraplen Smoothie 200 ml
- Aymes Crème 125 G
- Calshake 87 G sachet
- Enshake 96.5 G. Sachet
- Ensure 250 ml
- Ensure Plus 200 ml
- Ensure Plus 220 ml
- Ensure Plus Crème 125 G
- Ensure Plus Fibre 200 ml
- Ensure Plus Juce 220 ml
- Ensure Plus Savoury 220 ml
- Ensure Plus Yoghurt Style 220 ml
- Ensure Twocal 200 ml
- Forticreme Complete 125 G.
- Fortijuce 200 ml
- Fortisip 2 Kcal 200 ml
- Fortisip 200 ml
- Fortisip Multi Fibre 200 ml
- Fortisip Multi Fibre Savoury 200 ml
- Fortisip Yoghurt Style 200 ml
- Fresubin 2 Kcal 200 ml
- Fresubin 2 Kcal Crème 125 G Pot
- Fresubin 2 Kcal Fibre 200 ml
- Fresubin Energy 200 ml
- Fresubin Energy Fibre 200 ml
- Fresubin Jucy 200 ml
- Fresubin Original 200 ml
- Nutilis Fruit Stage 3 150 G Pot
- Nutricrem 125 G
- Scandishake Mix 85 G Sachet
If an oral nutritional supplement is not on list B, then, for now, there will be no pre-approval process required. So from a practice point of view, it is easier to just see products on List B as the Do not Dispense without pre-approval from the HSE and all other Oral Nutritional Supplements which do not appear on that list are fine to dispense on the schemes.
So in effect, there are also no changes to the reimbursement for the following categories of Oral Nutritional Supplements :
- Disease-specific ONS (e.g. renal-, diabetic-, oncology- and chronic obstructive pulmonary disease-specific sip feeds),
- High protein sip feeds,
- Pre-thickened sip feeds,
- Modular (single nutrient) ONS,
- Paediatric sip feeds,
It is also worth noting that this only applies to patients who get their nutritional supplements on the community drugs scheme (GMS, Hospital Emergency, LTI, DPS, HAA, etc). If a patient is “private” then there are no changes to them since they pay for their own medicines.
To read the full circular please click here