The Non-Insured Health Benefits Prescription Monitoring Program (NIHB-PMP)

Fact Sheet for Health Professionals
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The Non-Insured Health Benefits Prescription Monitoring Program (NIHB-PMP)

November 2014

What is the Non-Insured Health Benefits Program?

The Non-Insured Health Benefits (NIHB) Program is Health Canada's national health benefit program that provides coverage for medically necessary drugs, dental care, vision care, medical supplies and equipment, mental health counselling and medical transportation for eligible registered First Nations and recognized Inuit.

The NIHB Program aims to enhance the safe use of prescription medications and ensure that benefit criteria are met before claims are paid.

Why has NIHB implemented a Prescription Monitoring Program?

The NIHB Program has implemented a Prescription Monitoring Program (PMP) to address concerns over potential abuse and misuse of prescription medications which include benzodiazepines, opioids, stimulants and gabapentin.

The PMP is designed to identify and address potential client safety concerns regarding clients receiving high doses of these medications and/or prescriptions being obtained through multiple prescribers or multiple pharmacies.

Briefly, how does the NIHB-PMP work?

The PMP process includes a NIHB health professional reviewing anonymized drug profiles to identify patterns of concern. If a client's NIHB drug profile exceeds established thresholds including client seeking prescriptions from several different prescribers simultaneously and/or filling them at multiple pharmacies, this client could be placed in the PMP.

When a client is entered into the PMP they are asked to choose a single prescriber to write prescriptions for benzodiazepines, opioids, stimulants and/or gabapentin. This prescriber may become the sole prescriber for one or for more of these four classes of drugs. Once a prescriber has agreed to be the client's sole prescriber for these medications, NIHB will cover the cost of those eligible prescriptions, which can be dispensed at any pharmacy.

When the Program covers methadone or Methadose® in certain provinces or Suboxone® or Kadian® for clients for maintenance therapy for opioid addiction, clients are placed on specific restrictions similar to the PMP.

How will the NIHB-PMP resolve health and safety concerns?

When prescriptions for all of a client's benzodiazepines, opioids, stimulants and/or gabapentin are limited to a single prescriber, this ensures that the prescriber will be aware of ALL benzodiazepine, opioid, stimulant and/or gabapentin prescriptions covered for the client by the NIHB Program. The prescriber can then work with the client to assess the appropriateness of treatment.

Note: All other eligible medications on the NIHB drug benefit list will be covered as usual even if they are prescribed by other prescribers.

Who makes the decisions regarding the NIHB-PMP?

The NIHB-PMP is managed by Health Canada's NIHB Program health professionals. These health professionals oversee the clinical aspects and implementation of the NIHB-PMP in order to promote the safe use of benzodiazepines, opioids, stimulants and gabapentin. They provide recommendations on specific clients to be placed in the NIHB-PMP.

What will happen at the pharmacy?

Once the client has been placed in the PMP, the next time the client attempts to fill a prescription, the pharmacy will receive a rejection message and must call the NIHB Drug Exception Centre (DEC). After speaking to a DEC representative, the pharmacy receives (by fax) two copies of this Fact Sheet and the following three documents intended for the client:

  1. Letter to Client
    This letter will inform the client that in order for NIHB to continue paying for benzodiazepines, opioids, stimulants and/or gabapentin, they will have to choose only one prescriber to prescribe these medications.
  2. Prescriber-Acceptance Form
    This form must be completed by the prescriber of the client's choice who agrees to be their sole prescriber of benzodiazepines, opioids, stimulants and gabapentin. The signed form must then be submitted to the NIHB Program.
  3. Client-Prescriber Contract
    This is a tool to assist the prescriber and client in describing their agreement.

Will the pharmacy be paid for this work and interaction?

Yes. The pharmacy will be paid a usual and customary dispensing fee for providing the PMP package to the client when the client attempts to have a prescription filled for the first time after being placed in the NIHB-PMP. The pharmacist will be issued a Prior Approval for the client by the DEC for a specific pseudo-DIN (91500001) with which they will be able to submit a claim for a single dispensing fee.

The dispensing fee will cover the cost of:

  • calling DEC and speaking to the NIHB representative;
  • accepting the faxed documents from NIHB; AND
  • giving the three documents plus one copy of the Fact Sheet to the client. The other copy of the Fact Sheet is for the pharmacist.

If the client has difficulty understanding the documents, the pharmacist will be well positioned to explain the document contents and to direct the client to call their respective regional office for additional information.

What happens after the client has been given the three documents?

Until the client has chosen a single prescriber and NIHB has received a signed Prescriber-Acceptance Form, the NIHB Program will reject payment for claims submitted for benzodiazepines, opioids, stimulants and gabapentin by pharmacies.  However, DEC may authorize a one time 7-day supply of the medication in order for the client to find a sole prescriber for one or more of the four types of drugs. When approved, the pharmacist will be paid as usual to dispense the 7-day supply of the medication.

What does this mean for the prescriber?

When a client asks a prescriber to be their sole prescriber of benzodiazepines, opioids, stimulants and/or gabapentin, they should bring the three previously mentioned documents and one copy of the Fact Sheet to the prescriber's office. A prescriber is under no obligation to accept this request; however, if the prescriber accepts, they need to:

  • Sign the Prescriber Acceptance form and fax it back to NIHB. This will enable NIHB to resume coverage of prescriptions for benzodiazepines, opioids, stimulants and/or gabapentin.
  • Consider completing the Client-Prescriber Contract as a tool to clarify their agreement. If this optional contract is completed, it should also be faxed back to NIHB.
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