Doctors don’t know when to use it, Patients don’t understand it, Pharmacist pay for it and the Govern uses it.
What is a limited use code
also known as a reason for use code. it is a code the the Ontario government uses to limit the use of expensive drugs
Examples of drugs that require limited use codes are:
Ozempic
Rybelsis
Celebrex
Pantoloc
Example of Formulary Search
SEMAGLUTIDE
0.68mg/mL Inj Sol – Pref Pen 3mL Pk
Reason For Use Code Clinical Criteria
667 For the treatment of adult patients with type 2 diabetes when adequate glycemic control is not achieved on the maximum tolerated dose of metformin or where metformin is contraindicated or inappropriate.
Semaglutide is not funded in combination with another glucagon-like peptide-1 receptor agonist (GLP-1 RA) or dipeptidyl peptidase-4 (DPP-4) inhibitor.
Injectable semaglutide is not funded in combination with oral semaglutide. Coverage is only provided for one dosage format.
Reimbursed dose: As per the product monograph
LU Authorization Period: Indefinite
Medical doctors practicing in Ontario should know how to search for drugs on the Formulary to see which drugs are covered under the Ontario drug benefit program, which drugs require a limited use code and if the patient meets the criteria.
Scenario#1
The patient was admitted in the hospital and stabilized on a blood thinner. Upon discharge from the hospital the doctor prescribed Fragmin Inj 5000IU once daily for 14 days then follow up with the family doctor. The doctor did not know that Fragmin required a LU code so the patient has to wait for the pharmacist to contact the prescribing doctor to get a LU code in order to bill the government for payment.
Now there is a delay in the treatment, the patient is upset because they think the pharmacist does not want to give them their medication.
Scenario #2:
The patient goes to the doctor to get Ozempic for weight loss. Ozempic requires a LU code and it is only covered for diabetes. So this patient will have to pay out of pocket for the weight loss drug because they do not meet the criteria.
These are just a few examples of the challenges of LU codes in Ontario. Pharmacist have to be vigilant because when the government do an audit on the pharmacy they take thousands of dollars back if the prescriptions do not have the correct LU codes or if the patient does not meet the criteria.
Pharmacy business is challenging, patient think that drugs are free and if the doctor prescribes it then they are entitled to it. That is far from the reality.
