Provider Guide for Pharmacy Benefits: Non-insured Health Benefits
January 1, 2016
This guide provides information on Health Canada's Non-Insured Health Benefits (NIHB) Program and its policies relevant to pharmacy providers. It explains the extent and limitations of the NIHB Program's pharmacy benefits by describing the important elements of each associated policy. It also lists website addresses to provide quick access to related forms and more detailed Program information.
References to or the use of 'dispensing fee', 'usual and customary dispensing fee', or any variation thereof are subject to reimbursement up to the regional maximum of the Program.
Refer to the Pharmacy Claims Submission Kit, published by Express Scripts Canada, for the process to submit claims for payment of services rendered to eligible clients.
Table of Contents
- 1.0 Introduction
- 2.0 Benefit Description and Conditions
- 2.1 Terms and Conditions of Services
- 2.2 Drug Benefit List
- 2.3 Open Benefits
- 2.4 Limited Use Benefits
- 2.5 Prior Approval
- 2.6 Formulary For Chronic Renal Failure Patients
- 2.7 Palliative Care Formulary
- 2.8 Exceptions
- 2.9 Exclusions
- 2.10 Drug Utilization Review
- 2.11 Prescription Monitoring Program
- 2.12 Potential Drugs of Abuse (PDA) Program
- 3.0 Policies
- 3.1 Best Price Alternative
- 3.2 No Substitution
- 3.3 Prescription Quantities
- 3.4 Extemporaneous Mixtures
- 3.5 Opioid Addictions Treatment
- 3.6 Emergency Supply Process
- 3.7 Refusal to Fill Fee
- 3.8 Trial Rx Program
- 3.9 Manual Claims
- 3.10 Reversals for Prescribed Medication Not Picked Up by Client
- 3.11 Balanced Billing
- 3.12 Pharmacist Initiated Prescribing
- 4.0 Payment and Reimbursement
- 5.0 Appendices
Health Canada's Non-Insured Health Benefits Program is a national program that provides coverage to eligible registered First Nations and recognized Inuit for a specified range of medically necessary health related goods and services to which these individuals are not entitled through other plans and programs (provincial/territorial health or social programs, or other publicly and privately funded programs).
NIHB Program benefits include a specified range of prescription drugs and over-the-counter (OTC) medications, dental and vision care, medical supplies and equipment, short-term crisis intervention mental health counselling, and transportation to access medically required health services that are not available on the reserve or in the community of residence.
This Provider Guide for Pharmacy Benefits explains the policies under which the NIHB Program will reimburse pharmacy goods and services provided to eligible clients. As policies and procedures evolve, the guide is updated accordingly and pharmacy providers are advised of these changes through the Program's Newsletters.
Providers are advised to read and retain the most current version of the guide as well as Program Newsletters to ensure continued compliance with their Express Scripts Provider Agreement for the NIHB Program. In the event of a contradiction between versions of the guide, the provisions of the Health Canada web-posted guide will prevail.
2.0 Benefit Description and Conditions
The pharmacy, or drug component, of the NIHB Program covers drugs and over-the-counter medications that are included on the NIHB Drug Benefit List (DBL) and prescribed by an NIHB recognized health professional, licensed to prescribe in a given provincial jurisdiction, such as a physician.
Eligible pharmacy benefits are based on policies established by NIHB's Drugs and Therapeutics Advisory Committee (DTAC), Health Canada, and Canadian Agency for Drugs and Technologies in Health (CADTH), to provide eligible clients with access to benefits not otherwise available under federal, provincial, territorial, or private health insurance plans.
Pharmacy benefits are covered in accordance with the mandate of the NIHB Program. This includes 'open benefits' which are listed on the DBL and do not require prior approval, and 'limited use benefits' which are on the DBL and may be eligible for coverage, if the criteria for coverage are met.
Clients of the NIHB Program do not pay deductibles or co-payments.
2.1 Terms and Conditions of Services
To be eligible for payment of services rendered, pharmacy providers must adhere to the terms and conditions of the NIHB Program. These are detailed within the Pharmacy Claims Submission Kit, including the procedures for verifying client eligibility, claims eligibility, submission, adjudication, payment, reversals, and audit.
It is the pharmacist's responsibility to verify benefit eligibility for the client (at the time of dispensing), to ensure that no limitations under the Program will be exceeded, and to ensure compliance with NIHB benefit criteria and policies.
Please ensure the name indicated on the prescription matches the identity of the Status Card presented at the time of dispense. Note: all Alias names should be registered by the Client with the Department of Indigenous and Northern Affairs Canada (INAC).
2.2 Drug Benefit List (DBL)
The Program maintains a DBL of eligible drugs that are primarily used in a home or ambulatory setting. The DBL indicates to prescribers and pharmacy providers which drug products are eligible benefits. It is a tool to encourage prescribers and providers alike to select an optimal and cost-effective drug therapy. Pharmacy providers should regularly review the list to ensure that they continue to be aware of the drug benefits included. The DBL is published annually on the Health Canada website, and changes made to the DBL during the year will continue to be communicated via newsletters and fax broadcasts.
For an electronic version of the DBL, please refer to the Drug Benefit List 2016.
A prescription from a NIHB recognized licensed prescriber is required for any listed drug to be processed as a benefit under the NIHB Program. The prescriber must be in good standing with the appropriate governing body, province or territory in which they practice, and the prescription must be written in accordance with the applicable provincial or territorial prescriber guidelines. Prescribers include, but are not limited to, medical doctors, medical specialists, dentists, pharmacists, and nurse practitioners corresponding to respective provincial or territorial legislation and policies.
Drugs considered for, or currently listed on, the DBL must meet minimum criteria. For example, they must be legally available for sale in Canada with a Notice of Compliance (NOC). The drugs must also demonstrate evidence of therapeutic efficacy, safety, and incremental benefit in proportion to incremental cost.
NIHB Program drug benefits are based on the judgement of recognized health professionals, consistent with the best practices of health services delivery and evidence-based standards of care.
The review process for drug products that are considered for inclusion as a benefit under the NIHB Program varies depending on the type of drug submitted.
Submissions for new chemical entities, new combination drug products and existing chemical entities with new indications, must be sent to the Canadian Agency for Drugs and Technologies in Health (CADTH). Clinical and pharmacoeconomic reviews are coordinated by the Common Drug Review (CDR) Directorate and forwarded to the Canadian Drug Expert Committee (CDEC) for recommendations on formulary listing. These recommendations are forwarded to participating drug plans, including the NIHB Program, for consideration. The NIHB Program and other drug plans make listing decisions based on CDEC recommendations and other specific relevant factors, such as mandate, priorities, client safety and resources.
Submissions for line extensions, generics and all other submissions are reviewed internally or by the Drugs and Therapeutics Advisory Committee (DTAC). Generic drug products are considered for inclusion on the formulary based on provincial interchangeability lists and other relevant factors.
Should you have any questions regarding the DBL, please contact the Express Scripts Canada Provider Claims Processing Centre Toll-Free at 1-888-511-4666.
2.3 Open Benefits
Open benefits are drugs listed on the DBL which do not have established criteria, gender or age limitations, or prior approval requirements. This means that, in most cases, pharmacy providers may submit claims for dispensing 'open benefit' drugs without receiving prior approval requirements.
Open benefits may include specific eligible items in the following categories:
- prescription drugs;
- over-the-counter medications;
- injectable drugs, including injectable allergy serums;
- extemporaneous mixtures;
- drug delivery devices, as required, to deliver medications for certain conditions;
- recognized non-oral contraceptive devices; and
- therapeutic vitamins and minerals.
2.4 Limited Use Benefits
Limited use benefits are drug products listed on the DBL that may not be appropriate for general listing, but have value in specific circumstances. These products will have specific criteria for provision as a benefit under the NIHB Program. A product will be designated for limited use when:
- it has the potential for widespread use outside the indications for which benefit has been demonstrated;
- it has proven effectiveness, but is associated with predictable severe adverse effects;
- it is usually a second or third line choice for treatment and is required because of allergies, intolerance, treatment failure or noncompliance with a first line alternative; or
- it is very costly and a therapeutically effective alternative is available as a benefit.
There are three types of limited use benefits:
- Limited use benefits which do not require prior approval. These include but are not limited to:
- Multivitamins (which are benefits for children up to six years of age); and
- Prenatal and postnatal vitamins (which are benefits for women of childbearing age (12 to 50 years).
- Benefits which have a quantity and/or frequency limit. A maximum quantity of drug is allowed within a specified period of time. No prior approval is required for the recipient to obtain the allowable quantity of drug within the specified period. An example of a category of drugs with a quantity and frequency limit is smoking cessation products. Recipients are eligible to receive up to three treatment courses of nicotine replacement therapy (NRT) within a 12-month period with quantity limits, which include two courses of NRT patches and one course of NRT products used PRN (i.e. gums, lozenges, inhalers).
- Limited use benefits which require prior approval (using the "Limited Use Drugs Request Form"). Limited use benefits and the criteria for their coverage are identified in the Drug Benefit List. The criteria are also listed on the forms faxed to prescribers for completion.
2.5 Prior Approval
In addition to limited use benefits, some items not listed on the DBL may be considered for coverage under special circumstances, with prior approval.
Prior Approvals (PA) may be obtained by contacting the Drug Exception Centre (DEC) directly. In these instances, the DEC will require details about the prescription, the prescriber, the client and the pharmacy. To complete the PA process, the DEC may also fax an Exception or Limited Use Drugs Request Form to the prescriber for completion stating the medical need for the drug.
A PA may also be obtained automatically for a select group of Limited Use drugs via the electronic claims adjudication system when a claim is submitted meeting the criteria. If rejected, the provider may resubmit the claim electronically to have the PA request reviewed by the DEC. Providers should be aware that a representative from the DEC may call them directly to discuss the request or to collect any necessary information.
PA requests or rejected claims submitted to the DEC may take a few days to review, depending on the time it takes for the prescriber to provide any needed information. When approval is granted, a confirmation letter with the applicable dates and prior approval details will be faxed or mailed to the provider. Pharmacy providers are advised to retain the confirmation letter, if applicable, for billing purposes.
Prior approval for specific benefits does not provide approval for a price change unless also specifically requested. NIHB sets maximum costing limits for specific items. Any prices that exceed the maximum price require specific and separate approval by NIHB.
PAs are entered electronically in the claims processing system. The date of dispense should be indicated to the analyst so it can be reflected in the PA. When submitting the claim, providers must be sure to include the date of service (dispense date).
2.6 Formulary for Chronic Renal Failure Patients
Clients with chronic renal failure are eligible to receive a list of supplemental benefits that are not included in the DBL but which are required on a long-term basis. Some supplemental benefits include: darbepoetin alfa products (except in provinces where NIHB clients are eligible to receive darbepoetin alfa through the provincial programs), calcium products, multivitamins formulated for renal patients and select nutritional supplements formulated for renal patients.
New clients requiring drugs on the special formulary will be identified for coverage through the usual prior approval process. Once the client is confirmed as eligible, coverage will automatically be extended to all drugs in the special formulary for as long as needed.
2.7 Palliative Care Formulary
Clients who are diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included in the DBL.
When the DEC is informed that a client is palliative, a Palliative Care Application Form will be generated and faxed to the prescriber. Once completed and submitted, the client will be eligible for all medications on the Palliative Care Formulary if the following criteria are met:
- is not receiving care in a provincially covered hospital or provincially covered long-term care facility; and,
- has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within six months or less.
Once approved, the client will be eligible for all medications on the Palliative Care Formulary for six months without the need for further prior approval. If coverage is required beyond the initial six months, an additional six months may be granted upon receipt of another completed Palliative Care Application Form.
Exception drugs are drug products which are not listed in the DBL. These drug products may be approved in special circumstances upon receipt of a completed "Exception Drugs Request Form" from the licensed prescriber.
- when the prescription is for a recognized clinical indication and dose which is supported by published evidence or authoritative opinion; and,
- when there is significant evidence that the requested drug is superior to drugs already listed as program benefits; or,
- when a patient has experienced an adverse reaction with a best price alternative drug, and a higher cost alternative is requested by the prescriber; or,
- when there is supporting evidence that available alternatives are ineffective, toxic, or contraindicated (personal preference alone does not justify an exception).
Drugs are excluded from the NIHB Program as recommended by the Common Drug Review (CDR) and the NIHB Drugs and Therapeutics Advisory Committee (DTAC) because published evidence does not support the clinical value or cost of the drug relative to existing therapies, or there is insufficient clinical evidence to support coverage.
Exclusions are items not listed on the DBL and are not available through the exception or appeal processes. These include certain drug therapies for particular conditions which fall outside of the NIHB mandate and are not provided as benefits under the NIHB Program. They include, but are not limited to: anti-obesity drugs, household products, cosmetics, hair growth stimulants, and megavitamins. For a more complete list of exclusions, please refer to Appendix E in the DBL.
2.10 Drug Utilization Review
A drug utilization evaluation, which is part of the point-of-service or on-line adjudication system, provides an analysis of both previous claims data and current claims data to identify potential drug-related problems. Messages are returned to pharmacists to alert them of the potential problems. These messages are intended to enhance pharmacy practice with additional information. Currently, the system monitors for:
- potential drug/drug interactions
- duplicate drugs
- duplicate therapy
- early refill
As part of the NIHB Drug Use Evaluation (DUE) Program, DTAC reviews utilization patterns of medications billed to the NIHB Program and provides advice to promote effective, efficient and optimal drug therapy to First Nations and Inuit clients.
NIHB has a special warning message for the misuse of specific drugs of concern. These drugs include opioids, benzodiazepines and methadone. The warning message was designed to focus attention on cases where there were concerns about potential misuse, and where continued utilization was difficult to justify. The warning message, called the NE code, addresses situations where clients access:
- 3 or more active prescriptions for benzodiazepines;
- 3 or more opioids;
- 3 or more benzodiazepines and 3 or more opioids; or,
- a prescription for methadone in association with an opioid-based drug.
2.10.1 Intervention Codes
When pharmacy providers decide to override a reject message with an intervention code, they must complete and retain the appropriate documentation on the nature of the intervention directly on the prescription or on any hard or electronic version of the client file. To avoid the recovery of claim payment during the claims verification and audit process, proper documentation of any intervention is required. This should include:
- date of the intervention;
- summary of the intervention by the pharmacy provider;
- documented communication with the prescriber, caregiver, and/or client; and,
- reason for early refill (medication lost, destroyed, stolen, prescriber changed dosage, or client going out of town for a period greater than the days supply remaining of the current refill).
2.10.2 Lost Medications
In the event a client loses their medication, a provider can use an intervention code to override a drug utilization review reject message for "fill too soon". The prescription or client profile at the pharmacy must contain specific documentation citing the reason why the prescription was refilled early.
Pharmacy providers can decide to override a reject message with an intervention code, "MR". They must complete and retain the appropriate documentation on the nature of the intervention directly on the prescription or on any hard or electronic version of the client file. To avoid the recovery of claim payment during the claims verification and audit process, proper documentation of any intervention is required. This may include:
- date of the intervention;
- summary of the intervention by the pharmacy provider;
- documented communication with the prescriber, caregiver, and/or patient; and,
- reason for early refill (medication lost).
2.11 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 and/or multiple pharmacies.
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 medication for clients for the treatment of opioid addictions (see section 3.5 Opioid Addictions Treatment), clients are placed on restrictions similar to the PMP.
Once the client has been placed in the PMP, the next time the client attempts to fill a prescription for benzodiazepines, opioids, stimulants and/or gabapentin, the pharmacy will receive a rejection message and must call DEC.
After speaking to a DEC representative, the pharmacy receives by fax a copy of this Fact Sheet and the following two documents intended for the client:
- 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.
- 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.
The pharmacy will be paid a usual and customary (U&C) 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 PMP. The pharmacist will be issued a PA 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 two documents plus one copy of the Fact Sheet to the client. If the client has difficulty understanding the documents, the pharmacist may explain the document contents and direct the client to call their respective regional office for additional information.
For more information visit the NIHB Prescription Monitoring Program.
2.12 Potential Drugs of Abuse (PDA) Program
The NIHB Program has introduced a wide range of client safety measures to prevent and respond to potential misuses of prescription drugs to ensure that First Nations and Inuit clients can get the medications they need without being put at risk. These monitored drugs include: opioids, benzodiazepines, gabapentin and stimulants. The Program has introduced several strategies to monitor these medications which include: gradually reducing dose limits, the Prescription Monitoring Program (as described above), and reviewing the utilization of medications prescribed and dispensed for our clients.
The following policies impact the benefits under which the NIHB Program will reimburse pharmacy goods and services provided to eligible clients. As policies and procedures evolve, the guide is updated accordingly. Pharmacy providers are advised of these changes through the Program's Newsletters. Newsletters can be found at the Express Scripts Canada provider website.
3.1 Best Price Alternative
The NIHB Program covers the lowest cost equivalent (LCE) drug, which is often a generic drug. Generic drugs are considered for inclusion on the NIHB formulary based on provincial interchangeability lists and other relevant factors.
The NIHB Program will reimburse only the best price (lowest cost) alternative product in a group of interchangeable drug products. Pharmacists must follow their provincial/territorial pharmacy legislation/policies to identify interchangeable products and to select the lowest-priced brand. (NIHB may not necessarily reimburse at the cost listed in the provincial drug plan formulary).
The NIHB policy to reimburse the best price alternative product also applies to generic products not deemed interchangeable by the province or generic products not listed on the provincial formulary. For these drugs, the NIHB Program will only reimburse up to the best price (lowest cost) generic product available in the provincial formulary. If the pharmacist chooses a generic that is covered by the NIHB Program, but is not listed on the provincial formulary or interchangeability list, the claim will be reimbursed to the maximum of the provincially listed LCE price and the higher costs will not be reimbursed.
Among interchangeable over-the-counter (OTC) products, the maximum allowable price will be that of the LCE listed on the DBL.
3.1.2 Maximum Allowable Cost for Over-the-Counter (OTC) Medications
The NIHB Program has a maximum allowable cost (MAC) pricing model for select OTC medications. Pricing for medications will be determined through assessments of product accessibility and package sizing by province and territory which will ensure fairness to NIHB service providers while providing unit cost consistency. For example, all DINs for acetaminophen 500 mg are subject to the same MAC price. The OTC MAC pricing will be reviewed and updated regularly. Only oral tablets, capsules and caplets are included in the OTC MAC pricing model. The products that have a defined OTC MAC include: acetaminophen (Tylenol), acetylsalicylic acid (Aspirin), loratadine (Claritin), cetirizine (Reactine), and ibuprofen (Advil).
3.1.3 Package Size
Costing must be based on appropriate package sizing for quantities dispensed in pharmacies. This means that costs submitted by pharmacy providers must correspond to the actual cost for the product incurred by the pharmacy provider and not to costs relative to a package size that is more expensive. All claim submissions will be calculated on the basis of the lowest unit cost.
3.2 "No Substitution" Claims
NIHB will consider reimbursement for a higher-cost interchangeable product when a patient has experienced an adverse reaction with a lower-cost alternative. In such circumstances, the prescriber must provide the NIHB Program with:
- a completed and signed Canada Vigilance Adverse Reaction Reporting Form: 'Report of suspected adverse reactions to health products in Canada', and,
- the prescription with "No Substitution" or "No Sub" written by hand or typed on the prescription.
Upon receipt, the pharmacist will forward a copy of the prescription to NIHB for review. The prescriber is responsible for sending a copy of the form to the Canada Vigilance Program. Forms can be obtained by calling the Canada Vigilance Program at 1-866-234-2345, by downloading a copy, or by photocopying a copy from the Compendium of Pharmaceuticals and Specialties.
NOTE: The Canada Vigilance Adverse Reaction Reporting Form will not need to be resubmitted for renewals or new prescriptions of the same drug for the patient, although "No Sub" will still have to be written or typed on the prescription.
3.3 Prescription Quantities
The Program reimburses 100-days supply of chronic medications unless otherwise indicated by the prescriber. This ensures that certain medications required for long-term maintenance therapy are prescribed and dispensed efficiently.
The default maximum allowed dollar threshold for claims adjudication without a prior approval (PA) is $1999.99. Providers require a PA for claims that are over $1999.99. NIHB may set a lower maximum dollar threshold for specific items. Providers will be notified of these exceptions. Please contact the Express Script Canada Provider Claims Processing Call Centre for related questions.
3.3.1 Short-Term Dispensing
It is the Program's expectation that certain medications required for long-term maintenance therapy should be prescribed and dispensed in up to 100 days supplies. For refills for medications requiring short-term dispensing for a shorter time than 28 days due to compliance concerns, the Program will only reimburse a total of one dispensing fee per 28 days up to the regional maximum of the Program. These medications include (but are not limited to) the following:
- Antiemetics for cancer chemotherapy
- Alpha-adrenoreceptor Antagonists
- Anti-Parkinsonian Drugs
- Cardiovascular Drugs
- Drugs for Treatment of Bone Diseases
- Proton Pump Inhibitors
- H2-Receptor Antagonists
- Prokinetic agents
- Anti-dementia Drugs
- Anti-platelet aggregation Drugs
- Enzyme Preparations
- GI Anti-inflammatory Drugs
- Urinary Anti-Spasmotics
- OTCs (including vitamins)
- Synthetic antidiuretic hormone
- Anti-gout Drugs
- BPH Drugs
- Drugs for Diabetes
- Thyroid Therapy
- Other Drugs for Peptic Ulcer and Gastro-esophageal Reflux Disease (GERD)
- Respiratory smooth muscle relaxants
Note: This list may be amended as required and changes will be communicated through the quarterly online updates to the DBL. Medications on the Short term Dispensing list are identified in the DBL using the symbol ST beside the medication strength and dosage form.
The following are exceptions to the STD policy:
- Refills for intermittent treatment of a chronic disorder or refills of a medication which is prescribed to be taken on an "as needed" (PRN) basis. Note: Medications prescribed to be taken on an "as needed" (PRN) basis and dispensed chronically may be subject to audit and recovery.
- Prescriptions for dose changes.
- The following dosage forms: injectable and suppository.
- Refills or new prescriptions when prescribed/dispensed in accordance with a court order.
- Others as identified by the NIHB Program.
The compensation will be the lesser of the usual and customary fee up to the maximum negotiated NIHB regional dispensing fee for each 28 days supplied. NIHB will continue to audit and recover in instances where quantity reduction occurs.
Less than 28 Day Supply
For the medications listed below in which short-term dispensing is deemed medically necessary, the Program will compensate up to one full dispensing fee every seven days, up to the regional maximum of the Program. If these medications are dispensed daily, the Program will compensate 1/7th of this fee:
- Nicotine Replacement Therapy
- Needles & Syringes
- Drug used in nicotine dependence
- Antimanic agents
When filling a new prescription for a chronic use drug, the Program will pay a full dispensing fee regardless of the days supply. A new prescription may include a dosage change or an intermittent treatment, based on an assessment by a prescriber.
When refilling a prescription for a chronic use drug that is for less than a 28 day supply or when a need for compliance packaging is identified by the prescriber, the Program will pay no more than one full dispensing fee per 28 day period. For the medications listed above the Program will pay no more than full dispensing fee per 7 day period.
A refill is defined as the second and all subsequent fills for a given strength and dosage of a drug.
3.3.2 Opioid Dispensing
As part of its Prescription Drug Abuse Strategy, the NIHB Program has a 30-day maximum dispense policy for all opioids. The policy applies to all open benefit and limited use opioids covered under the Program, as well as to other opioids that are not listed, but are covered on a case-by-case basis.
One (1) full dispensing fee will be paid per 30-day dispense (or less, if prescribed in a smaller quantity). Where opioids are prescribed to be dispensed for a longer duration as a single prescription, NIHB will reimburse up to a maximum of 30 days at a time. For audit purposes, prescriber approval to split a prescription into 30-day dispenses will not be required for opioids. Please be advised that the claims processor is unable to automatically cut back the day supply to 30 days. Providers are expected to manually apply the policy.
This policy does not apply to claims submitted according to the NIHB Opioid Addiction Treatment Policy (please refer to section 3.5 Opioid Addictions Treatment).
Visit the NIHB Opioid Dispensing Frequency for additional information.
3.3.3 Maximum Quantities
Benefits that have a quantity and frequency limit do not require prior approval as long as the maximum quantity of the drug is not exceeded within a specified period of time. For example, NIHB clients are eligible to receive up to three treatment courses of nicotine replacement therapy (NRT) within a 12-month period with quantity limits, which include two courses of NRT patches and one course of NRT products used PRN (i.e. gums, lozenges, inhalers). This is renewable only 12 months from the day the initial prescription was filled.
Please refer to the DBL for drug specific quantity and frequency limits.
3.4 Extemporaneous Mixtures
To be eligible under the NIHB Program, extemporaneous mixtures (compounds) must have at least one ingredient listed on the DBL and must not duplicate the formulation of commercially manufactured drug products. Mixtures that contain exception or limited use drugs must receive prior approval by the DEC; those that contain ingredients excluded from the Program will not be eligible for coverage.
All extemporaneous mixtures must be submitted with the corresponding pseudo-DIN to be reimbursed appropriately. Pharmaceutical powders of eligible ingredients may be used in lieu of tablets/capsules. These powders must be billed at AAC and must not exceed the maximum allowable AAC which is based on the price of the DIN of the comparable listed tablet or capsule.
For eligible topical extemporaneous mixtures only, below is a list of eligible non-medicinal bases:
- Glaxal Base
- Petrolatum (Vaseline)
- Cold cream
- Compound tincture of benzoin (Friar's balsam)
- Ihle's paste
- Mineral oil
- Lassar's paste
- Cocoa Butter
- Zinc oxide creams/ointments
Reimbursement for the following types of extemporaneous mixtures will be reviewed on a case-by-case basis by the DEC:
- Requests for payment for preparing sterile syringes where no alterations are required to the product prior to drawing up the syringe. Providers are reminded that clients should first access alternate health coverage when available (e.g. through provincial home care programs). Consideration will be given to the following when determining approvals: client/caregiver ability to draw up medication into a syringe, and requirements for specialized equipment (e.g. cytotoxic medications).
- Topical products compounded for transdermal drug delivery (e.g. analgesics in PLO gel).
List of ineligible ingredients and products:
- Products which recreate commercial products that are available in the same strength unless there is a shortage/back-order of these products (prior approval required)
- Investigational products
- Hair growth stimulants, e.g., minoxidil in topical preparations
- Fertility and impotence drugs, e.g., Caverject
- Compounded preparations containing any hormones
- Homeopathic preparations
- Natural Health Products
- Products used for cosmetic purposes
- Reconstitution of a dry powder oral preparation with distilled water in accordance with its product monograph
- Reconstitution of non-sterile commercially available products such as BenzaClin
- Pre-made parenteral infusion bags where no alterations are required to the product prior to administration
- Reimbursement for supplies used in the process of compounding (e.g. alcohol wipes, syringes, needles, papers, etc.)
- Reimbursement for supplies used to dispense final product (e.g. ointment jars, bottles, syringes, atomizers, nasal spray bottles, eye droppers, etc.)
- Reimbursement for non-essential, non-medicinal ingredients (e.g. flavourings, sweeteners, etc.)
- Topical mixtures where the only eligible medicinal ingredient is hydrocortisone, camphor or menthol in strengths less than 0.5%
For more information, please contact the Provider Claims Processing Call Centre at 1-888-511-4666 to speak with an Express Scripts Canada Representative.
3.5 Opioid Addictions Treatment
The opioid addiction compensation model allows for up to one $4.60 fee to be billed per day for witnessing the ingestion of all strengths of Suboxone or Kadian and any instances where the client may be taking more than one medication for opioid withdrawal (e.g. methadone and Kadian). If the client is receiving methadone, the witness fee is automatically included in the fee calculation so another witness fee will not be allowed in the billing.
Providers are encouraged to contact the NIHB claims processor, Express Scripts Canada at 1-888-511-4666 should they have questions concerning the fee structure for opioid addictions treatment.
NIHB compensates compounded methadone (pseudo-DIN 00908835) or, where required by provincial regulations, commercially available methadone solution (e.g. Methadose) for the treatment of opioid dependence.
The NIHB Program has specific requirements for drug cost, mark-up, and dispensing fees when billing methadone for the treatment of opioid dependence. This applies to both witnessed and carried doses. The dispensing fee for methadone is based upon the following formula for each day of methadone treatment (Dispensing Fee/7) + $4.60.
For claims filled on the same day, the electronic claims adjudication system will allow a single transaction up to a maximum seven-day supply or more than one transaction for a combination of up to a maximum seven-day supply. Pharmacy providers should be aware that NIHB will only pay claims from one provider per day and only if the total "days supply" has elapsed from a previous date of service. Claims are to be submitted reflecting the date of service provided.
When billing for compounded methadone solution for the treatment of opioid dependence (pseudo-DIN 00908835), the quantity submitted must be in milligrams (mg) of drug dispensed prior to any dilution. For example, if a physician prescribed 75 mg of methadone each day, the claim submission must indicate a quantity of 75 mg of methadone.
When billing for Methadose for the treatment of opioid dependence, the quantity submitted must be in millilitres (mL) of drug dispensed prior to any further dilution. For example, if a physician prescribed 75 mg of methadone each day, the claim submission must indicate a quantity of 7.5 mL of Methadose 10mg/mL oral solution.
Suboxone is subject to the NIHB STD policy and is to be billed according to the package DINs (DIN 02295695, 02295709). The Program will compensate pharmacists up to one usual and customary dispensing fee every seven days. If Suboxone is dispensed daily, the Program will compensate 1/7th of the U&C dispensing fee. When dispensed less frequently than every seven days, such as once a month, the pharmacist will be entitled to one full dispensing fee.
NIHB may approve an additional fee of $4.60 for each day the ingestion of Suboxone is witnessed in the pharmacy (using pseudo-DIN 91500002).
NIHB will consider covering Kadian for the treatment of opioid dependence where methadone and Suboxone are not available or not appropriate. When used to treat opioid addiction, Kadian is subject to the NIHB STD policy and is to be billed according to the pseudo-DINs as listed below:
The Program will compensate pharmacists up to one U&C dispensing fee every seven days. If Kadian is dispensed daily, the Program will compensate 1/7th of the U&C dispensing fee. When dispensed less frequently than every seven days, such as once a month, the pharmacist will be entitled to one full dispensing fee.
NIHB may approve an additional fee of $4.60 for each day the ingestion of Kadian is witnessed in the pharmacy (using pseudo-DIN 91500002).
3.6 Emergency Supply Process
When a drug requiring prior approval is needed on an emergency basis and the criteria for automated PA have not been met (i.e., a claim is submitted on-line and prior approval is not electronically granted, as indicated by the generated CPhA message) and/or access to the DEC is not possible (i.e., statutory holidays and after hours of operation), a pharmacist may dispense an initial course of treatment (maximum seven-day supply). It is important that the pharmacist contact the DEC as soon as possible for an approval to be back-dated to cover the emergency supply. This approval number must be included when submitting the seven day emergency supply claim.
If the item is eligible for auto PA, but did not meet the criteria, the provider should resubmit the rejected claim with applicable intervention code to initiate the prior approval process as soon as possible so that the DEC can review the request for NIHB emergency supply coverage. Refer to the Pharmacy Claims Submission Kit for information on how to re-submit a request.
After an emergency dispense, providers must follow the usual prior approval process to dispense the balance of the prescription. If a PA is granted for the remainder of the prescription, the pharmacist will receive a prior approval number and details of the approved benefit by mail or fax. The prior approval number must then be included on the subsequent submitted claim.
Claims submissions for drugs dispensed as an emergency supply during regular hours of operation of the DEC are subject to reclaim.
3.7 Refusal to Fill Fee
A pharmacy provider in British Columbia, Saskatchewan, or Manitoba may decide not to fill or refill a prescription when a claim has been rejected through the Drug Utilization Review (DUR) and it is deemed to be in the best interest of the client. In these cases, a fee equal to the provider's usual and customary fee may be charged to the NIHB Program. The provider is advised to re-submit the original claim and use the 'UL' intervention code (please refer to the Pharmacy Claims Processing Submission Kit for more information).
3.8 Trial Rx Program
In British Columbia and Saskatchewan, the NIHB Program may cover the dispensing fee associated with the provision of a small initial quantity of a 'trial drug' (seven-day supply) that is included under the Trial Prescription Program. To be applicable for reimbursement, the client must not have used the drug within the past two years. Please refer to the Pharmacy Claims Submission Kit for details on adjudicating Trial Rx Program claims.
3.9 Manual Claims
Drugs of potential abuse require close monitoring by health care providers, such as physicians and pharmacists, to maximize safety and effectiveness and minimize the risk of harm, abuse and diversion. In order for the Program to provide coverage for these medications appropriately, information about drug claims must be received in an accurate and timely fashion. The adjudication system for the NIHB Program, Health Information and Claims Processing Services (HICPS) ensures this by adjudicating claims in real time. In order to ensure client safety and Program integrity, all claims for methadone, Suboxone, opioids, benzodiazepines or stimulants must be adjudicated at the point of sale. Provider manual claims and client reimbursement will not be permitted for these drugs.
3.10 Reversals for Prescribed Medication Not Picked Up by Client
When a client hasnot picked up a prescription within 30 days, the original paid claim must be reversed and resubmitted for payment of just the dispensing fee.
The submission of a claim for a dispensing fee where the client has not picked up a drug, which can be re-inserted to inventory, only applies to drugs with a dispensing fee dollar value. Once the original claim containing both the dispensing fee and the drug item cost has been reversed, the Provider must submit a claim using pseudo-DIN 55555555 in the DIN No./Item Number field. The information on the new claim, with the exception of pseudo DIN 55555555, must mirror that of the reversed claim. Items that are dispensed daily but not picked up should be reversed but are not eligible resubmission for payment of the dispensing fee.
Where the drug item is an eligible compound and reinsertion into the pharmacy's inventory is not possible, Express Scripts Canada pays the Provider for both the drug and dispensing fee. Therefore, a reversal is not necessary. DUR is not affected.
3.11 Balanced Billing
Pharmacy providers are required to submit to the NIHB Program their usual and customary dispensing fee as cited in their Pharmacy/Medical Supplies and Equipment Provider Agreement and to provide updates to these fees.
The maximum dispensing fees accepted by the Program are negotiated by the NIHB Program. Any dispensing fees exceeding the difference between the pharmacy's U&C dispensing fee to cash paying customers and the maximum allowed dispensing fee are not to be charged for NIHB clients.
3.12 Pharmacist Initiated Prescribing
The NIHB Program will accept claims for pharmacist initiated prescriptions for First Nations and Inuit clients such as to treat lice, smoking cessation and specific women's health issues (follow-up oral contraception, prenatal vitamins and folic acid, nausea and vomiting in pregnancy and vaginal candidiasis), where allowed by provincial and territorial legislation. Please refer to your provincial or territorial regulatory authorities for specifics related to the extended scope of practice in your area, as they differ between provinces or territories and as this section may not apply to your situation. NIHB will reimburse these prescriptions as per usual regional reimbursement policies of the Program.
NIHB continues to review expanded scope of practice legislation in each region and determine which additional conditions or minor ailments may be added to the list of items for which pharmacist initiated prescribing is accepted by the Program.
The reasons for prescribing and client specific details must be documented as per the provincial and territorial legislation and be available for review if necessary on audit. NIHB does not compensate pharmacists for professional services including the cost of assessing the client.
4.0 Payment and Reimbursement
4.1 Coordination of Benefits
Persons eligible for the NIHB Program are required to access any public or private health plan or provincial/territorial programs for which they are eligible before accessing NIHB. Pharmacy providers must confirm with each client whether other coverage exists because a claim must be submitted to the other party first for processing. Once this party processes the claim, the provider may then submit to NIHB for payment.
4.1.1 Coordination with Ontario Drug Benefit (ODB) Program
For eligible NIHB clients that are over 65 years of age or Social Service recipients, Ontario pharmacists must coordinate drug benefits and pursue payment through the Ontario Drug Benefit (ODB) program prior to billing the NIHB Program.
For drugs listed on the ODB Limited Use Benefit list, Ontario pharmacists must obtain prior approval through ODB before billing the NIHB Program. This may require contacting the prescriber to determine if the client meets ODB criteria. Results must be documented and kept on file in the NIHB client's profile for review during on-site audit. Failure to maintain proper documentation will result in reclaim.
Claims coordinated with the ODB program will be reimbursed in accordance with ODB's Condition on the Payment of Dispensing. NIHB will reimburse providers the ODB co-pay and deductible when billed in accordance with program requirements. Please note in the case of discrepancies between the ODB dispensing fee policy and the NIHB STD policy and in the absence of the ODB dispensing fee policy, the NIHB policy takes precedence.
For coordination of benefits, for eligible patients, between ODB and NIHB, the following rules apply:
- Claims are to be adjudicated through ODB first, then through NIHB as the second payer (i.e. NIHB will only reimburse the copay or deductible as applicable).
- For drugs eligible for coverage under ODB through Limited Use (LU) benefit, claims must be adjudicated through ODB first. In the event that a patient does not meet the ODB LU eligibility criteria, the claim can be processed directly through NIHB. Proper documentation must be kept on file (e.g. confirming diagnosis with prescriber or reason for ineligibility through ODB).
- For short-term dispensing claims, ODB policy allows for up to 2 dispensing fees per month while NIHB policy allows for 1 dispensing fee per month. In a coordination of benefit instance, NIHB will mirror the ODB policy (i.e. NIHB will allow a second copay to be adjudicated within a calendar month). NIHB will pay the copays for ODB coordinated claims, however, once the maximum number of fees have been paid by ODB in a month, NIHB will not pay additional dispensing fees.
4.1.2 Termination of Alternative Coverage
When an eligible client no longer has benefit coverage through another private or public health care plan or social program, claims submitted to the NIHB Program requires a letter from the plan or program, stating that they are no longer eligible under their previous plan. A record of this change must be kept on any hard or electronic version of the client's file, stating that they no longer have third party coverage with the effective termination date.
For additional information on Coordination of Benefits, please refer to the Pharmacy Claims Submission Kit.
4.2 Dispensing and Claims Submission
Upon signing the Pharmacy Provider Agreement with the NIHB Program's claims processor, pharmacy providers are advised to read and retain an up-to-date Pharmacy Claims Submission Kit. This Kit outlines all of the accountability rules and obligations for providers to ensure that they have the information they need to submit claims for payment.
There are a few obligations that bear repeating in this guide. Pharmacy providers, for example, have one year from the date of service to secure payment, and completion of the days supply field with the appropriate number of days of treatment is mandatory for all claims submitted electronically and on NIHB pharmacy claim forms. The following policies also carry important requirements for providers:
- The provider should submit claims for payment for the acquisition cost of products on the Drug Benefit List which were provided, and the lesser of: (i) the Usual and Customary Professional Fee (dispensing fee) and (ii) any maximum for such fees as set out in any regional schedules for professional fees referred to in the Pharmacy Claims Submission Kit.
- When accessing benefits through the NIHB Program, eligible clients may not directly or indirectly benefit from special promotions or incentives, including coupons, discounts, points or rebates in the form of cash and/or goods that may be offered by providers. To the extent permitted by such promotions and applicable law, the coupons, discounts or rebates should be applied to the NIHB claim.
- When a client hasnot picked up a prescription within 30 days, the original paid claim must be reversed and resubmitted for payment of just the dispensing fee. This is applicable only to drugs with a dispensing fee dollar value.
5.1 Glossary of Key Terms
- AAC: Actual Acquisition Cost
- CADTH: Canadian Agency for Drugs and Technologies in Health
- CDEC: Canadian Drug Expert Committee
- CDR: Common Drug Review
- CPhA: Canadian Pharmacists-Association
- DBL: Drug Benefit List
- DEC: Drug Exception Centre
- DTAC: Drugs and Therapeutics Advisory Committee
- DUE: Drug Use Evaluation
- DUR: Drug Utilization Review
- FNIHB: First Nations and Inuit Health Branch at Health Canada
- HICPS: Health Information and Claims Processing Services
- INAC: Indigenous and Northern Affairs Canada
- LCE: Lowest cost equivalent (best price alternative)
- LU: Limited Use
- MAC: Maximum allowable cost
- NIHB: Non-Insured Health Benefits
- NRT: Nicotine Replacement Therapy
- NOC: Notice of Compliance
- OAT: Opioid Addiction Therapy
- ODB: Ontario Drug Benefit
- OTC: Over-the-counter products
- PA: Prior Approval
- PMP: Prescription Monitoring Program
- PRN: medication taken "as needed"
- STD: Short-Term Dispensing
- U&C: Usual and Customary Dispensing Fee
5.2 Client Eligibility
To be eligible for NIHB Program benefits, a person must be a Canadian citizen and have the following status:
- a registered Indian, recognized by Indigenous and Northern Affairs Canada (INAC), according to the Indian Act; or,
- an Inuk recognized by one of the following Inuit Land Claim organizations - Nunavut Tunngavik Incorporated, Inuvialuit Regional Corporation, Makivik Corporation. For an Inuk residing outside of their land claim settlement area, a letter of recognition from one of the Inuit land claim organizations and a birth certificate are required; or,
- an infant, less than age one (1), whose parent is an eligible client; and,
- currently registered or eligible for registration, under a provincial or territorial health insurance plan; and,
- not otherwise covered under a separate agreement with federal, provincial or territorial governments.
To facilitate verification, pharmacy providers should request the client's Status Card at each visit in order to provide the following client identification information in each claim:
- surname* (under which the client is registered);
- given names* (under which the client is registered);
- date of birth (dd/mm/yyyy); and,
- client identification number.
*Pharmacy providers should ensure that the name on the prescription relates to the Status Card name. Document discrepancies accordingly for Alias names on the prescription or the electronic patient file.
It is recommended that pharmacy providers ask clients to present their identification card upon each visit to ensure that client information is entered correctly and to protect against mistaken identity.
For recognized Inuit clients, one of the following identifiers is required:
- Government of the Northwest Territories health plan number, which begins with the letter "T" and is followed by 7 digits. This number is valid in any region of Canada and is cross-referenced to the First Nations and Inuit Health Regional Office Client identification number.
- Government of Nunavut health plan number, which is a 9-digit number starting with a "1" and ending with a "5". This number is valid in any region of Canada and is cross-referenced to the FNIH client identification number.
- FNIHB Client Identification Number (N-Number), which begins with the letter "N" and is followed by 8 digits. This is a client identification number issued by the First Nations and Inuit Health Branch at Health Canada to recognized Inuit clients.
For eligible First Nations clients, one of the following identifiers is required:
- Indigenous and Northern Affairs Canada (INAC) registration number, which is a 10-digit number. Treaty or Status number, this registration number is the preferred method of identifying First Nations clients.
- Band Number and Family Number, where applicable.
- FNIHB Client Identification Number (B-Number), which begins with the letter "B" and is followed by 8 digits.
For infants under one year of age who are not yet registered with Indigenous and Northern Affairs Canada or applicable Inuit associations, pharmacy providers must submit the first claim for manual processing to Express Scripts Canada using the NIHB Pharmacy Claim Form. Subsequent claims may be submitted for this infant via point of service with the parent's primary identifier in the client identification number field and the infant's identifiers in the surname, given name, and birth date fields.
More detailed information about client eligibility is included in section 4.1 of the Pharmacy Claims Submission Kit.
5.3 Privacy Statement
For more information on Health Canada's privacy practices, please contact the Health Canada/Public Health Agency of Canada Privacy Management Division at 613-948-1219 or by email at firstname.lastname@example.org.
5.4 Appeal Process
Persons eligible for the NIHB Program have the right to appeal the denial of a benefit with the exception of items that are identified as exclusions or insured services. If a client seeks information about the appeal process, pharmacy providers may direct them to the online appeal procedures, or to the appropriate Health Canada regional office.
5.5 Audit Program
The NIHB provider audit program ensures that the NIHB Program is accountable for the expenditure of public funds. The Health Information and Claims Processing Services (HICPS) contractor performs this audit function by verifying paid claims against pharmacy records to confirm that the claims have been billed in compliance with the terms and conditions of the NIHB Program. Claims are verified according to NIHB Program policies as well as Terms and Conditions which include valid prescriptions. This validity is determined by federal and provincial / territorial acts and regulations as well as policies and standards of practice of the provincial / territorial College of Pharmacists or equivalent regulatory body.
Detailed information about audit procedures and the responsibilities of pharmacy providers for these audits are included in section 5.0 of the Pharmacy Claims Submission Kit.
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