Non-Insured Health Benefits Program Updates

These updates give First Nations and Inuit clients the latest news on NIHB policies and benefit coverage.

November 2019

Pharmacy benefit information

New formulary for nutrition products

On October 1, 2019, the NIHB program added a special formulary for clients with a medical need for nutrition products such as thickening agents, infant formulas and nutritional supplements. Products are listed for infants, children and adults.

The Nutrition Products Formulary is available in Appendix I of the Drug Benefit List. These products are listed as limited use (prior approval required). If you have a prescription for a medically necessary nutrition product, your pharmacist can contact the NIHB Drug Exception Centre at 1-800-580-0950 to request approval for coverage.

Increased coverage of test strips and lancets for clients using insulin

On October 1, 2019, coverage for blood glucose test strips and lancets increased to 8 per day of each item for clients who manage their diabetes with insulin.

New coverage for Ozempic

NIHB has listed Ozempic as an open benefit. Ozempic is covered in combination with metformin for the treatment of type 2 diabetes.

New coverage for lidocaine ointment

Lidocaine 5% ointment is now covered as an open benefit. NIHB covers up to 35 grams per month with a prescription. Lidocaine ointment is used to reduce pain or itching caused by skin irritations such as insect bites, poison ivy, minor cuts or burns.

Coverage status change for zinc

Elemental zinc is now covered as an open benefit. It may be prescribed to patients to support wound care related to a chronic condition, such as type 2 diabetes.

Medical Supplies and Equipment (MS&E) information

New MS&E benefit coverage

The NIHB Program has added the following new MS&E benefits. These are limited use benefits (prior approval required):

  • standing frames, positioning seats and portable ceiling lifts and tracks
  • FM systems (a type of assistive hearing device)
  • voice restoration equipment and accessories
  • electric breast pumps when required for certain medical conditions, to a maximum price of $275

Change in coverage for select MS&E items

On September 9, 2019, the NIHB program increased coverage for mastectomy bras and gender-affirming bras to 3 per year.

On November 18, 2019, laryngectomy products were added as open benefits. Also, coverage for Heat Moisture Exchangers (HMEs) increased to 1 per day (open benefit). HME devices are used to make breathing easier following a laryngectomy or a tracheostomy.

New recognized prescribers for MS&E benefits

Nurse practitioners are now recognized by the NIHB program as prescribers of limb and body orthotics and prosthetic devices.

Speech-language pathologists have been added as recognized prescribers for laryngectomy supplies and for certain voice restoration equipment and accessories.

Hearing reassessment for children and youth with hearing devices

On November 18, 2019, the NIHB program increased coverage to allow for more frequent hearing reassessments for children and youth under 18 years of age with hearing devices:

  • The first year a client under 18 has a hearing device, they are entitled to 4 reassessments.
  • The second year a client under 18 has a hearing device, they are entitled to 2 reassessments.
  • After 2 years, clients under 18 with hearing devices are entitled to one hearing reassessment per year.

For more information on all MS&E benefit and policy changes, please refer to the Guide for Medical Supplies and Equipment Benefits and the Medical Supplies and Equipment Benefit Lists.

General program information

Reminders: provider billing and client reimbursement

Many providers are enrolled with NIHB and paid directly by the program, so clients do not have to pay out of pocket for eligible benefits. NIHB recommends that before you receive any item or service, you should speak with your provider's office to confirm that:

  • the provider is enrolled with NIHB and will bill the program directly
  • the item or service is fully covered by NIHB
  • the provider will not charge you any additional fees

If you are planning to pay up front for benefits and then seek client reimbursement from NIHB, you should contact NIHB before purchasing items or receiving services to confirm that:

  • the provider is recognized by NIHB as eligible to provide the product or service
  • the requested item or service is eligible for coverage under the NIHB Program
  • the provider's rate for the product or service is fully covered by NIHB

July 2019

Vision Care Benefit Information

Changes to Corrective Eyewear Coverage

The NIHB Program recently announced changes to the coverage of corrective eyewear, including new coverage amounts based on your prescription. There are two key coverage amounts: standard and high index. These changes took effect on June 29, 2019. Please consult the new Vision Care Benefit Guide for complete information.

Pharmacy Benefit Information

Changes to Pediatric Nutrition Coverage

Effective June 26, 2019, certain infant formulas will be added as Limited Use benefits. These products will be covered when medically necessary for infants up to one year of age. These new listings can be found in section 96:00 of the Drug Benefit List, with more details on coverage criteria in Appendix A.

In addition, multivitamins will now be covered until the age of 19 and the list of multivitamins has been expanded. Please consult section 88:28 of the Drug Benefit List for more information.

Listing Status Change for Nabilone

Effective June 24, 2019, nabilone is now an open benefit for adult clients over 18 years old. Nabilone is a medication that is used to treat severe nausea and vomiting caused by cancer treatment (chemotherapy). The dose coverage limit for nabilone is six milligrams per day, which is the maximum recommended daily dose for this medication.

New Benefit for Treatment of Atopic Dermatitis (Eczema) in Children

Effective June 24, 2019, non-medicated emollient cream (Glaxal Base and similar products) is a limited use benefit for the treatment of atopic dermatitis (eczema) for clients age 18 and under. NIHB covers up to 450 grams per month.

Emollients are non-cosmetic moisturisers that can help reduce the severity of eczema, as well as the amount of medicated cream that is needed. If your child has eczema, ask your health provider if a non-medicated emollient cream could be an effective treatment option.

Information for Clients in Ontario: Coordination of Benefits with OHIP+

Through OHIP+, the Government of Ontario provides prescription drug coverage for children and youth (24 years of age and under) who do not have coverage through a private health benefit plan.

Children and youth who are eligible under both OHIP+ and the NIHB Program may access coverage through either Program. If you want your pharmacist to submit your (or your child's) pharmacy claims to NIHB, please make sure to present client identification.

For assistance, please contact the Ontario NIHB Navigators at 1-877-517-6527, or the NIHB Drug Exception Centre at 1-800-580-0950.

Dental Benefit Information

New Coverage of All-Porcelain/Ceramic Crowns

Effective July 1, 2019, the NIHB Program has added all-porcelain/ceramic crowns as eligible dental benefits. All other guidelines and criteria for coverage of crowns remain in effect, and can be found in Section 8.3.5 of the NIHB Dental Benefits Guide.

Medical Supplies and Equipment (MS&E) Benefits

Increased Coverage for Washable Bed Pads

NIHB now covers 6 washable bed pads (underpads) per year, increased from 2 per year. If they are needed on a long-term basis, your provider should contact the NIHB regional office to request a special authorization. Once a special authorization is set up, the provider can dispense these items in the future without prior approval.

Complete Hearing Assessments Changed to Open Benefits

Complete hearing assessments are now open benefits. They are covered by NIHB without prior approval, once every 5 years. You or your doctor may request a hearing reassessment after 2 years if you notice any change in your condition. Your audiologist should contact the NIHB regional office to request prior approval for early reassessment. More information can be found in the Audiology Benefits List.

Coverage for Cochlear Implant Processors and Bone Anchored Hearing System Processors

Cochlear implant processors and bone anchored hearing system processors (including soft band if required) are now listed by NIHB as limited use benefits (prior approval required). They are eligible for replacement once every 5 years.

Details on coverage criteria, prescriber/provider requirements and replacement guidelines can be found in Section 3 of the Guide for Medical Supplies and Equipment Benefits and in the Audiology Benefits List.

New Listing - BPAP ST Device

Effective April 9, 2019, bilevel positive airway pressure with spontaneous and timed breathing (BPAP ST) devices are now listed as limited use benefits (prior approval required). This device may be appropriate for clients with respiratory failure. Talk to your health care provider about whether a BPAP ST device could be right for you. For more information please refer to the Guide for Medical Supplies and Equipment Benefits under Section 9 Respiratory Equipment and Supplies.

General Program Information

Reminder – Effective Dates

When the NIHB Program announces new benefit coverage or a new reimbursement rate, these changes start on the "effective date". This means that the change applies to eligible items or services received by the client on and after this date. The new coverage or rate will not apply to items or services received before the effective date.

June 2019

Vision Care Benefit Information

Upcoming Changes to NIHB Eyewear Coverage

On June 29, 2019, NIHB will make changes to coverage of corrective eyewear (glasses and contact lenses). These changes will make it easier to understand your coverage and will offer more choice — you will be able to use your coverage towards the purchase of any type of prescription eyewear.

These rates will be in effect for eyewear ordered on or after June 29, 2019:
Standard Coverage Amount $275* For prescriptions that are less than ±7.0 (minimum prescription strength will continue to apply). This is the most common rate.
High Index Coverage Amount $415* For prescriptions that are ±7.00 or higher.
* Clients in the Northern Territories and Atlantic region can contact their regional office for information on applicable rates.

How often you are covered for eyewear will not change. Children 0-17 years are eligible once a year; clients 18 years and older are eligible once every two years; clients whose prescription changes a lot may be eligible for early replacement of the lenses. However, frequency periods will be changed to a calendar year basis. For example, for an adult who is eligible every two years, if you get new eyewear at any time in 2019, you will be eligible again on January 1, 2021.

There will be no change to the policy on exceptions. As was the case before, some clients will qualify for more coverage (reimbursement amount or frequency) based on their medical need.

You can check the new Vision Care Benefit Guide or contact your regional NIHB office for more information about these changes.

April 2019

Pharmacy Benefit Information

Reduction of Dose Limit for Benzodiazepines – Ontario and Northern Regions

To help ensure the safety of clients, the NIHB Program is further lowering the dose limit for coverage of benzodiazepines. This change is being implemented region by region, and will take effect in Ontario and Northern regions (Yukon, Nunavut and Northwest Territories) on May 13, 2019.

Some clients may be exempt from these dose limits. Pharmacists should call the NIHB Drug Exception Centre when dose limits are reached.

Pharmacist Recommendation for Wart Treatments

Medications to treat warts were recently added to the list of items that do not require a doctor's prescription and are covered by NIHB when recommended by a pharmacist. You can find a complete list of eligible products and medications that can be recommended by pharmacists in section 3.13 of the NIHB Guide for Pharmacy Benefits.

If you or your pharmacist have questions about this policy, please call the NIHB Drug Exception Centre at 1-800-580-0950.

Dental Benefit Information

New Coverage for Root Canal Re-Treatment

The NIHB Program has expanded coverage under its Endodontic Policy to include new eligible services for re-treatment of root canals. These services require predetermination. You can find more information on frequency and eligibility criteria in section 8.4 Endodontic Services of the NIHB Dental Benefits Guide.

Service Standards for Predetermination

Certain dental procedures require a predetermination (PD), where the NIHB Program reviews the request to confirm eligibility for coverage before the service is provided. The NIHB Program aims to provide a decision on coverage of predetermination requests within 15 business days, starting from the day that NIHB receives the submission from your dental provider. This service standard may not apply in special circumstances, such as human or environmental disaster (e.g. fire, power outage, equipment failure).

If a predetermination request is missing information, the NIHB Dental Predetermination Centre will communicate with your dental provider to request the information, and put the request on hold. The 15 day review period restarts when NIHB receives the missing information from your provider.

Clients and providers may call the NIHB Dental Predetermination Centre at 1-855-618-6291 (Dental Services) or 1-866-227-0943 (Orthodontic Services) to inquire about the status of predetermination requests.

Medical Supplies and Equipment (MS&E) Benefits

Recognition of Occupational Therapists and Physiotherapists to Recommend Selected MS&E

NIHB will now accept written recommendations from registered Occupational Therapists (OT) and Physiotherapists (PT) for coverage of certain medical supplies and equipment. When recommended by an OT or PT, a prescription from a doctor is no longer required. This includes many items in the General Benefits List, as well as the Limb and Body Orthotics, Pressure Garments and Pressure Orthotics Benefit Lists.

For more information on eligible items and prescription/recommendation requirements, please consult the Medical Supplies and Equipment Benefit Lists.

Coverage for 'Back-Up' Wheelchairs

NIHB clients using a power wheelchair are now eligible for a standard manual wheelchair, to be used as a 'back-up' (for example, if the power wheelchair is under repair). Prior approval for coverage of a second wheelchair is required. Please check section 2.4 (h) of the Guide for Medical Supplies and Equipment Benefits for more information.

Increased Coverage for Silver Alginate Wound Dressing

The maximum number of silver alginate dressings that can be claimed without prior approval has increased to 20 per year (increased from 10 per year). Additional dressings may be covered with prior approval if there is a medical need. More information on these and other wound care benefits is available in section 1.8.3 of the General MS&E Benefits List.

New Benefit - Pessary

Vaginal pessaries have been added as open benefits (under 'Pessary'). They are used to treat pelvic organ prolapse and urinary incontinence. More information can be found under 'Pessary' in section 1.7 of the General MS&E Benefits List.

New Listing - Medical stroller

Medical strollers are now listed as limited use benefits (prior approval required). Previously, they were covered on exception. More information on coverage criteria and guidelines can be found in section 2.4 (h) of the Guide for Medical Supplies and Equipment Benefits and in section 1.5.3 of the General MS&E Benefits List.

Increased Rate for Custom-made Foot Orthotics

On April 1, 2019, the NIHB Program increased the reimbursement rate for a pair of custom-made foot orthotics to $474.26 (unless the price is subject to a separate agreement between a provider group and the NIHB Program). If you purchased a pair of custom-made foot orthotics on or after April 1, 2019, you may be reimbursed at the new rate. More information can be found in the Custom-made Shoes and Foot Orthotics Benefits List.

January 2019

Pharmacy Benefit Information

Updated Drug Benefit List

The January 2019 Drug Benefit List (DBL) is now available. The DBL is a listing of drugs and products covered by the NIHB Program and is updated several times during the year. Please refer to Appendix H, 'New Listings' to see medications and products added since the last publication of the DBL in October 2018.

December 2018

Pharmacy Benefit Information

Coverage for Multiple Sclerosis Medications

On January 2, 2019, NIHB will list eleven medications for treatment of multiple sclerosis (MS) as limited use benefits with criteria. Previously, these medications were covered only on exception. The medications are listed below, and coverage criteria can be found in Appendix A of the NIHB Drug Benefit List.

Brand Name Active Ingredient
Avonex interferon beta-1a
Betaseron interferon beta-1b
Rebif interferon beta-1a
Extavia interferon beta-1b
Plegridy peginterferon beta-1a
Copaxone glatiramer acetate
Glatect glatiramer acetate
Tecfidera dimethyl fumarate
Aubagio teriflunomide
Gilenya fingolimod
Lemtrada alemtuzumab

New Listing for Diabetes Medication

NIHB now covers Tresiba (insulin degludec) pre-filled pens as open benefits. This change adds another option for once-daily insulin therapy for adults with diabetes.

Benefits Recommended by Pharmacists

NIHB has added epinephrine auto-injectors (EpiPens) and some contraceptive products to the list of non-prescription (over-the-counter) benefits that can be prescribed or recommended by pharmacists. This means that you don't need a prescription from a doctor or nurse practitioner for coverage of these benefits.

You can find a complete list of eligible products and medications that can be prescribed or recommended by pharmacists in section 3.13 of the NIHB Guide for Pharmacy Benefits.

If your pharmacist doesn't know about this policy, please ask them to call the NIHB Drug Exception Centre at 1-800-580-0950 for information.

Client Safety Program

NIHB has changed the name of the Prescription Monitoring Program (NIHB-PMP) to the Client Safety Program (NIHB-CSP). The new name better reflects the aim of the program, which is to support the safety of clients who are prescribed medications that have a risk of problematic use or dependence, such as opioids. Clients are enrolled in the NIHB-CSP based on their prescription drug claim history, or if they are being treated for opioid use disorder (for example, with methadone or Suboxone). Clients in the NIHB–CSP must have the same prescriber (or clinic) for opioid, benzodiazepine, stimulant and/or gabapentin prescriptions.

Reduction of Dose Limit for Benzodiazepines – Alberta

To help ensure the safety of clients, the NIHB Program is further lowering the dose limit for coverage of benzodiazepines. This change is being implemented region by region, and will take effect in Alberta region on February 11, 2019.

Some clients may be exempt from these dose limits. Pharmacists should call the NIHB Drug Exception Centre (DEC) when dose limits are reached.

Update on Coverage for Smoking Cessation Treatments

Smoking cessation therapies are used to help people quit smoking. Some people need more than one patch at a time to control cravings, and may combine patches with other forms of nicotine replacement therapy. NIHB clients are now eligible in a 12-month period for coverage of:

  • Up to 36 boxes of patches (7 patches per box)
  • One 12-week course of treatment, like gums, lozenges, and inhalers, or spray

If you reach your limit on smoking cessation products but want to try quitting again, ask your pharmacist to call the Drug Exception Centre and you may be eligible for more. NIHB will cover these over-the-counter products when they are recommended or prescribed by a pharmacist, so you don't need a prescription from a doctor.

The Program also covers Zyban and Champix, which are prescription medications used to help people quit smoking. Please talk to your health care provider about the right products and therapies for you.

Dental Benefit Information

New Coverage of Fluoride Treatment for Adults

On December 5, 2018, the NIHB Program increased coverage of fluoride treatment to include clients 17 years of age and older with a frequency of one fluoride treatment in any 12-month period. Previously, the coverage was only for clients under 17 years of age. With this change, clients of all ages are eligible for coverage of fluoride treatment.

Change to Dental Sedation Policy

NIHB revised its dental Sedation and General Anaesthesia Policy and removed the predetermination (PD) requirement for minimal sedation (nitrous oxide and oral sedation). These benefits are now listed as Schedule A (open benefits).

Medical Supplies and Equipment (MS&E) Benefits

Registered Nurses as Prescribers for Certain MS&E Benefits

NIHB will now accept prescriptions or written recommendations from registered nurses (RNs) for some MS&E benefits. This includes items in the categories of bathing and toileting aids, dressing aids, feeding aids, transfer aids, walking aids, incontinence, ostomy and catheter supplies, wound care supplies and breast prostheses. A complete list of these items is available in the Medical Supplies and Equipment Benefit Lists.

Additions to the MS&E Benefit Lists

On December 17, 2018 NIHB added new items to the MS&E benefit lists. These items were previously covered only on exception, and are now listed benefits with criteria (prior approval required). New listings include:

  • offloading walking and diabetic walking boots
  • custom foot bed liners
  • orthosis for club foot
  • wheeled commodes (for purchase)
  • oxygen conserving devices (rental)

Please consult the Guide for Medical Supplies and Equipment Benefits and Medical Supplies and Equipment Benefit Lists for more information on Program policies (including prescriber and provider requirements), price and frequency guidelines for these benefits.

Change in Listing Status for Off-the-shelf Limb and Body Orthotics

A range of off-the-shelf limb and body orthotics (e.g. splints, braces) are now open benefits. Prior approval for coverage is not needed if these items are provided within Program price and quantity guidelines. You can check the Limb and Body Orthotics Benefits List for more information.

October 2018

Pharmacy Benefit Information

Temporary NIHB Coverage for AUVI-Q (Epinephrine Auto-Injector)

Due to a shortage in the supply of EpiPen auto-injectors in Canada, the NIHB Program is providing temporary open benefit coverage for AUVI-Q epinephrine auto-injectors. Health Canada has recently allowed the import of AUVI-Q auto-injectors from the United States.

Epinephrine auto-injectors are used to deliver an emergency treatment of adrenaline (epinephrine) when a person is having a life-threatening allergic reaction (anaphylaxis). The AUVI-Q auto-injector delivers the same dose of medication as EpiPen, but has a retractable needle.

More information on AUVI-Q for patients is available online.

September 2018

Pharmacy Benefit Information

Reduction of Dose Limit for Benzodiazepines

To help ensure the safety of clients, the NIHB Program will lower the dose limit for coverage of benzodiazepines beginning in Saskatchewan and Quebec on September 17, 2018, and Atlantic region on November 13, 2018. Effective dates for other regions will be announced in future Program Updates.

Benzodiazepines (for example, diazepam) are sedatives used to treat conditions such as seizures, anxiety or insomnia. Beginning in 2013, the NIHB Program has been gradually reducing the benzodiazepine dose limit to ensure they are used safely.

Some clients may be exempt from these dose limits. Pharmacists should call the NIHB Drug Exception Centre (DEC) when dose limits are reached.

Change in Coverage of Diabetic Lancets

Beginning on October 9, 2018, coverage for diabetic lancets will change so the Program's quantity guideline is in line with blood glucose test strips. Lancets are used to prick the skin when you test your blood sugar. You are eligible for one lancet for each test strip. The quantity guideline for test strips has not changed, so this will not affect how often you can test.

NIHB coverage of test strips and lancets is based on recommendations from the Canadian Agency for Drugs and Technologies in Health (CADTH) (PDF) for checking your own blood sugar. The number of times a day that you should test depends on the type of medication you are using to manage your diabetes. The new quantity guidelines for coverage of lancets are shown in the table below.

Diabetes Treatment Number of lancets covered How often you can test
Clients managing diabetes with insulin 600* / 100 days Up to 5 times per day
Clients managing diabetes with diabetes medication with high risk of causing low blood sugar 400 / 365 days Once a day
Clients managing diabetes with diabetes medication with low risk of causing low blood sugar 200 / 365 days 3 to 4 times per week
Clients managing diabetes with diet/lifestyle therapy only (no insulin or diabetes medications) 200 / 365 days 3 to 4 times per week

*The test strip limit is 500/100 days. The limit for lancets is 600/100 days because of different package sizes.

NIHB recognizes that some clients may need to test more often. If you need more lancets and/or test strips, your pharmacy provider can contact the NIHB Drug Exception Center (DEC) Center for prior approval. One additional box of strips and/or lancets may be approved over the phone and provided right away. DEC will then contact your health care provider for information to support the request for additional coverage.

Dental Benefit Information

Use of Sedation for Dental Procedures

Dental work is often performed in a chair using local anesthesia (freezing) to avoid pain during a dental procedure. If you or your child cannot get dental treatment using only local anesthesia, sedation can be used to ensure treatment is completed. Sedation should only be used for patients with severe anxiety, or who are unable to remain still during dental treatment.

Different types of sedation are used in dentistry, ranging from minimal sedation to general anesthesia. Examples of sedation types used with dental treatment are:

  • Minimal sedation, such as nitrous oxide/oxygen ("laughing gas") with or without an oral medication, can relax patients during treatment. The patient remains fully conscious.
  • Moderate sedation, usually delivered through injection, can help patients be more cooperative and less anxious. The patient is relaxed and may not be able to speak, but is not asleep.
  • Deep sedation and general anesthesia are most often used during major dental surgery, or for children who need a lot of dental work and cannot tolerate treatment in the dental chair. The patient is unconscious during treatment and must be monitored closely.

If sedation is suggested for you or your child, talk to your dentist about which type would be best to address your needs, as well as any potential risks or side-effects. Sedation is usually safe, but there may be complications such as nausea, vomiting or difficulty breathing. Deep sedation and general anesthesia have rare, but more serious health risks (for example, brain damage). For this reason, dental providers should use, when possible, the mildest type of sedation that is needed to complete the treatment.

NIHB covers all types of sedation, including general anesthesia, for children and adults. If you want to know more about coverage for sedation and general anesthesia services, please call the NIHB Dental Predetermination Centre or check the NIHB Dental Benefits Guide.

Medical Supplies and Equipment (MS&E) Benefits

Gender Affirming Benefits

NIHB has added a number of items as open benefits to support gender identity. No prior approval is needed within Program price and quantity guidelines. Examples of such items include upper body garments (e.g., binders), lower body garments (e.g. gaffs), packers, bra inserts and stand-to-pee (STP) devices.

You can find more information on policies and items covered in the Guide for Medical Supplies and Equipment Benefits and Medical Supplies and Equipment Benefit Lists. Please call your NIHB Regional Office for more information on how to access gender affirming MS&E benefits.

Change in Listing Status for Selected Mobility and Personal Care Items

Various mobility and personal care items are now covered by NIHB as open benefits. Prior approval is no longer needed for coverage of the following items when they are provided within Program price and frequency guidelines:

  • Bath Chair
  • Commode, Standard
  • Elevated Raised Toilet Seat with Arms
  • Floor to Ceiling Pole
  • Grab Bar-Bed Purchase
  • Safety Frame for Toilet
  • Tub Transfer Bench
  • Walker Standard, Purchase
  • Walker 2-wheel, Purchase
  • Walker 4-Wheel, Purchase
  • Walker Bariatric, Purchase
  • Wheelchair Manual, Purchase

More information on Program policies and guidelines for these items can be found in the Guide for Medical Supplies and Equipment Benefits and Medical Supplies and Equipment Benefit Lists.

Your MS&E provider can contact the Express Scripts Canada Provider Claims Processing Call Centre to confirm Program guidelines and client eligibility before providing these items.

Additions to the MS&E Benefit Lists

On September 21, 2018, NIHB will add new items to the MS&E Benefit Lists. Some of these items were previously covered as exceptions, but were not listed benefits.

  • Nipple shields for nursing mothers will be added as open benefits. No prior approval is required up to a maximum quantity of 12 in 6 months, to a maximum price of $15.00 each.
  • Electronic blood pressure (BP) monitors (with an arm cuff only) will be listed as open benefits. No prior approval is required for up to $100.00 per monitor with a recommended frequency guideline of one per 5 years.
  • Bi-Level Positive Airway Pressure (BPAP) and Auto-Continuous Positive Airway Pressure (APAP) systems will become listed benefits (prior approval is required).
  • Battery powered portable bath lifts will become listed benefits (prior approval required). This includes standard and bariatric bath chair lifts for purchase or rental, as well as batteries and repairs.

Please consult the Guide for Medical Supplies and Equipment Benefits and Medical Supplies and Equipment Benefit Lists for more information on Program policies (including prescriber and provider requirements), price and frequency guidelines for these benefits.

General Program Information

Exceptions to Price, Quantity or Frequency Guidelines

Many items and services are covered under NIHB without prior approval. These are called 'open benefits', or 'Schedule A' services (for dental benefits). These benefits often have Program guidelines for the maximum price, number of items or frequency of service that NIHB covers.

Based on your medical needs, NIHB may cover more of these items or services (or, at a higher price) on an exception basis, with prior approval. Your benefit provider can submit a prior approval or predetermination request for additional coverage. You or your provider can contact the NIHB Program for more information about what information is required.

July 2018

Dental Benefit Information

Updated Orthodontic Policy

Effective July 30, 2018, the Non-Insured Health Benefits (NIHB) Program introduced an updated Orthodontic Policy. The updated policy, which includes criteria for orthodontic coverage, can be found in section 8.8 of the NIHB Dental Benefits Guide.

The Orthodontic Policy has been updated to include an evaluation tool (Modified HLD Index) listing objective clinical criteria for orthodontic coverage. The updated policy also clarifies that pain or discomfort associated with a severe and functionally handicapping malocclusion is considered as part of NIHB's review of each case, when supported with objective clinical dental/medical evidence.

Clients who did not receive approval for orthodontic coverage between March 24, 2016 and July 31, 2018 can resubmit their original request to have it reviewed under the updated criteria by providing:

  • A signed letter from the client, parent or legal guardian, requesting a reconsideration of the case, and
  • Pre-treatment orthodontic diagnostic records (i.e., models, radiographs and photographs) which can be obtained through your orthodontist.

Clients who have questions about a specific case or request for coverage (including appeals) are encouraged to call the NIHB Dental Predetermination Centre (DPC) – Orthodontic Services line at 1-866-227-0943.

Pharmacy Benefit Information

Updated Drug Benefit List

The spring 2018 Drug Benefit List (DBL) is now available. The DBL is a listing of drugs and products covered by the NIHB Program and is updated several times during the year. Please refer to Appendix H, 'New Listings' to see medications and products added since March 2018.

June 2018

Pharmacy Benefit Information

More Coverage for Nicotine Patches

On May 14, 2018, the NIHB Program increased coverage for nicotine patches to 252 patches (36 boxes of 7) of any listed brand, within a 12-month period. If you need more patches covered, please ask your pharmacy provider to call the Drug Exception Centre.

Benefits Recommended by Pharmacists

To improve client access to benefits, NIHB has added new products and medications to the list of non-prescription (over-the-counter) benefits that can be prescribed or recommended by pharmacists. This means that you don't need a prescription from a doctor or nurse practitioner for coverage of these benefits:

  • Ibuprofen or acetaminophen to treat fever in children 11 years and under
  • Pediatric multivitamins for children 11 years and under
  • Vitamin D supplements for any age
  • Spacer devices for inhalers

You can find a complete list of eligible products and medications that can be prescribed or recommended by pharmacists in the NIHB Guide for Pharmacy Benefits.

Medical Supplies and Equipment (MS&E) Benefits

Special Authorization – MS&E Items Needed on an Ongoing Basis

To reduce the need for prior approval requests, NIHB may provide a special authorization for certain medical supplies needed on a long-term basis (for example, incontinence or ostomy supplies) when they have price and quantity guidelines. Once a special authorization is set up, you can get these items without prior approval. Your provider will need to request prior approval only if the price or number of items is higher than Program guidelines (the amount the Program normally covers).

Your MS&E provider can call the NIHB Regional office to ask if an item qualifies for a special authorization.

Mental Health Counselling Benefit

Updated Mental Health Counselling Guide

NIHB has recently updated the Guide to Mental Health Counselling Services. The Program will cover up to 22 hours of professional mental health counselling per year, including individual, family, or group counselling. Requests for additional counselling will be considered on a case-by-case basis. To support timely access to service, the first 2 hours of counselling do not require prior approval. No prescription or referral is required.

Mental health counsellors, including psychologists and social workers with clinical counselling certification, can enrol with NIHB to bill the Program directly. To find an enrolled mental health counsellor in your area, please contact the NIHB office in your region.

Mental Health Counselling through Telehealth

Did you know that you may be able to access mental health counselling via telehealth? The NIHB Program covers mental health counselling provided through telehealth, including telephone or video conferencing.

Many counsellors now offer this service to their clients. It is recommended that your first appointment with a mental health counsellor be in person, so that you and your counsellor can discuss if counselling via telehealth is right for you. You can choose face-to-face counselling if you prefer.

The technology (i.e. video conferencing or telephone) used, and where you use it, will be determined by your counsellor based on your needs and what is available. Your counsellor has a professional obligation to make sure that your privacy is protected. If you have any questions or concerns, you should speak to your counsellor in advance.

For more information on NIHB coverage of mental health counselling, please check the Guide to Mental Health Counselling Services.

May 2018

Important Message for NIHB Clients Evacuated Due to Manitoba Forest Fires

If you need to refill or replace items that were covered by the NIHB Program, here is the information you need to know.

Medications

If you need to replace or refill a prescription for medication, please contact one of the following: your assigned Red Cross Coordinator, Grand Medicine Pharmacy at 204-885-0768 or Muskehki Pharmacy at 204-772-1534 (select #4) or toll-free at 1-877-544-5521. If possible, please be ready to provide details for your prescription or medication. If you don't know the details of your prescription, the pharmacist may be able to look it up for you, or they can call the NIHB Drug Exception Centre (DEC). You may also call the DEC directly at 1-800-580-0950 (select #3) or contact the Manitoba Regional office at 1-800-665-8507 to be transferred to the DEC.

Dental services

Please contact the NIHB Dental Predetermination Centre at 1-855-618-6291 or the Manitoba Regional NIHB Dental Unit at 1-866-908-9320.

Medical supplies and equipment, vision care (including eyewear), and mental health counselling

Please contact the NIHB Regional Office in Manitoba at 1-800-665-8507.

Medical Transportation Referral Unit (RU) call centre

NIHB in the Manitoba region has a medical transportation call centre that provides 24-hour service and can be reached at the following toll-free number: 1-877-983-0911.

March 2018

Pharmacy Benefit Information

New Coverage of Nasal Naloxone

Effective March 27, Narcan Nasal Spray became an open benefit under the NIHB Program.

Narcan Nasal spray is a form of naloxone, used to treat opioid overdose. It may be requested for your personal use, or to protect an at-risk person. You don't have to specify who it is for, however it must be billed to NIHB under the name of the eligible client who is requesting it (even if it is not for their personal use). NIHB will accept a prescription or recommendation from a pharmacist for coverage of Narcan Nasal Spray.

NIHB Drug Exception Centre Now Taking Client Calls

Effective March 13, 2018, the NIHB Drug Exception Centre (DEC) will receive calls from clients related to medication benefit inquiries. The DEC call centre is staffed by NIHB personnel who deal only with pharmacy benefits, and are very knowledgeable about NIHB pharmacy benefit coverage and policies. You may contact the DEC directly 1-800-580-0950 ext. #3, or contact your Regional office and they will transfer your call to the DEC.

Updated Drug Benefit List

The Winter 2018 Drug Benefit List (DBL) is now available. The DBL is a listing of drugs and products covered by the NIHB Program and is now updated several times during the year. Also, there is a new section of the DBL – Appendix H, 'New Listings' – that lists medications and products added since the last update.

Expanded Coverage for Treatment of Hepatitis C

The NIHB Program covers medications for the treatment of chronic hepatitis C. NIHB has expanded coverage criteria so clients at any stage of the disease are now eligible for coverage of these medications. If you have been diagnosed with hepatitis C, talk to your health care provider about your treatment options.

New Coverage of Metoject

Effective January 10th, 2018, Metoject (a brand name of methotrexate pre-filled syringes) was listed as an open benefit of the NIHB Program.

Methotrexate is a drug that is used to treat autoimmune conditions such as rheumatoid arthritis or severe psoriasis. Methotrexate can be taken in oral (pill) or injectable forms. The injectable form of the medication comes in pre-filled syringes, to make it easier and more convenient for health care providers or patients to use.

New Coverage for Medication to Treat Attention Deficit Hyperactivity Disorder

Attention Deficit Hyperactivity Disorder (ADHD) in adults and children is often treated with a medication that contains a mixture of the stimulants amphetamine and dextroamphetamine. This medication is commonly known by the brand name Adderall XR, or the generic term 'mixed amphetamine salts XR'.

Effective April 9, 2018, NIHB will list mixed amphetamine salts XR as an open benefit. Previously, it was not listed in the DBL and was covered only on an exception basis. As with other medications containing stimulants, to help ensure client safety, a maximum dose and 30-day dispensing limit will apply.

Formulary for Adjunct Medications Used During Cancer Treatment

The NIHB Program has established a new formulary to make it easier for clients to access adjunct medications when they are undergoing cancer treatment.

Patients undergoing cancer chemotherapy or radiation can experience side effects such as nausea, diarrhea, anemia, and increased risk of infections. There are many different medications available to help ease these side effects. These are known as 'adjunct' medications, because they are used along with the primary cancer treatment.

Clients taking oral chemotherapy drugs covered by NIHB are now automatically approved for access to all of the medications on the adjunct formulary. If a client is receiving cancer treatment at a hospital, prior approval will be required only the first time that a client accesses a medication on the NIHB adjunct cancer formulary. After that, they will be automatically approved for all other medications on the list. Clients undergoing cancer treatment have open access to the adjunct formulary for a period of six months. If cancer treatment is longer, access to the formulary will be extended as long as the treatment continues.

The Adjunct Cancer Medications Formulary can be found in Appendix D of the NIHB DBL. NIHB also covers many other adjunct medications used during cancer treatment as open benefits, which can be found throughout the DBL.

New Coverage of Antibiotic Skin Cream and Ointment

Effective February 19, 2018, Fucidin H cream and Polysporin Triple ointment became open benefits under the NIHB Program. These products are used to treat different types of skin infections.

Dental Benefit Information

NIHB Partial Denture Trial Project

On February 19, 2018, the NIHB Program started a national trial project that makes it easier for providers to submit predetermination requests for partial dentures. The project also gives providers more flexibility to choose the type of partial dentures for their clients. You can talk to your dental provider for more details.

Medical Supplies and Equipment (MS&E) Benefits

New Coverage for Completely-in-Canal Hearing Aids

As of March 26, 2018, completely-in-canal (CIC) hearing aids will be listed as a benefit of the Program. CIC hearing aids require prior approval and are eligible for replacement every 5 years.

Please talk to your audiologist about your hearing aid device options. Other policies and guidelines for NIHB coverage of audiology benefits can be found in section 3.2 of the NIHB Guide for Medical Supplies and Equipment Benefits.

Increased Reimbursement Rate for Custom-Made Foot Orthotics

Effective April 1, 2018, the NIHB Program will increase the reimbursement rate for custom-made foot orthotics to $463.60 per pair (unless the price is subject to a separate agreement between a provider group and the NIHB Program).

MS&E providers enrolled with NIHB will bill the Program directly. NIHB recommends that you contact your MS&E provider before you receive an item or service to confirm that the provider is enrolled with NIHB, that the item or service is fully covered, and that the provider will not charge you any additional fees. If your provider will not provide the item or service at NIHB Program rates, please contact the First Nations and Inuit Health Branch (FNIHB) regional office for assistance finding another enrolled provider.

Change in Prescriber Requirements for Continuous Positive Airway Pressure (CPAP) Benefits

The NIHB Program will now accept prescriptions from nurse practitioners for diagnostic testing of sleep apnea and for treatment of obstructive sleep apnea with CPAP, BiPAP (bilevel positive airway pressure) and Auto-PAP (auto-titrating positive airway pressure) benefits. This change applies in provinces and territories where prescribing these benefits is within nurse practitioners' professional scope of practice. For more information on CPAP benefits, please consult section 3.7 of the NIHB Guide for Medical Supplies and Equipment Benefits.

General Information

Update on the Transition to Department of Indigenous Services Canada

On December 4, 2017, the Government of Canada created the new department of Indigenous Services Canada. Programs and services delivered by the First Nations and Inuit Health Branch (FNIHB), including NIHB, have become part of Indigenous Services Canada. Services to NIHB clients are not affected by this change, and NIHB Program contact information remains the same until further notice. You may notice some small changes to NIHB publications and pages on the Canada.ca website (for example, references to Indigenous Services Canada, instead of Health Canada). If you have any questions, please contact us at NIHB-SSNA@hc-sc.gc.ca.

Information for Parents and Guardians of NIHB-Eligible Infant Children

In order to allow time for parents to register their infant children, NIHB has extended coverage of unregistered infants up to 18 months of age. Infants up to 12 months of age may access most types of NIHB benefits under the identification number of their parent or guardian who is NIHB eligible. Contact the NIHB Dental Predetermination Centre if dental services are required for an unregistered infant.

After their first birthday, a child needs his or her own status or N number to process NIHB benefits. If your child has reached the age of 1 and you require additional time to register them, please call your NIHB Regional Office. You will be provided with a temporary NIHB client number that is valid until your child reaches 18 months of age.

Parents and guardians of infant children are encouraged to apply for registered Indian status or recognition from their Inuit land claims organization as soon as possible to ensure their child's access to NIHB benefits. For additional information on registration of First Nations infants, contact your Band Office or visit the Government of Canada website. For Inuit infants, contact your land claims organization.

Reminder of One-Year Reimbursement Policy

Please be reminded that all claims for client or provider reimbursement must be received by the NIHB Program within one year from the date of service to be eligible for reimbursement. The item or service must be an eligible benefit under the NIHB Program on the date of service, and will be subject to coverage policies in effect on that date. If a claim is rejected due to missing information, it can be re-submitted to NIHB with required information, as long as it is still received within one year from the original date of service.

December 2017

Pharmacy Benefit Information

Vitamin D Supplements

Vitamin D is a nutrient that helps your body use calcium to build and maintain b bones and teeth. Vitamin D supplements are covered by NIHB for clients of all ages with a prescription, and pharmacists can prescribe or recommend vitamin D supplements for infants and children.

Fatty fish and egg yolks are natural sources of vitamin D, and in Canada it is added to milk and other food products. Vitamin D is also made in your body when your skin is exposed to the ultraviolet light in sunshine. Some people get enough sunlight to maintain healthy levels of vitamin D, but many don't – especially if they live in a climate where there isn't much sunlight during the winter. Not enough vitamin D can cause rickets in children, or osteoporosis (fragile bones) in adults.

Health Canada recommends a vitamin D supplement for all breast-fed infants up to one year of age, and for all adults over 50 years of age. Children and adults may also benefit from a Vitamin D supplement. Talk to your health care provider to see if it is recommended for you.

Medical Supplies and Equipment (MS&E)

Registered Midwives as Prescribers

Effective November 28, 2017, NIHB recognizes registered midwives (RM) as prescribers of MS&E benefits within their scope of practice. This means that, in provinces and territories where midwifery is a regulated health profession, midwives can prescribe pregnancy-related items that are covered by the NIHB Program such as medical grade compression stockings, maternity belts and breast pumps.

Increased Coverage for Breast Pumps

On December 11, 2017, manual breast pumps will become an open benefit when prescribed by an NIHB-recognized health provider (physician, nurse practitioner or midwife). Prior approval from NIHB will no longer be required and the Program will pay up to a maximum of $65 for a manual breast pump for the birth of each child. For more information, please refer to section 3.1.4. of the Guide for Medical Supplies and Equipment Benefits.

Update on Prior Approval for a Pair of Custom-Made Foot Orthotics

On October 17, 2016, the NIHB Program lifted the prior approval requirement for a pair of custom-made foot orthotics (CMFO) for a trial period of 12 months. The Program will extend this change until March 31, 2018.

Please be reminded that the NIHB Program will pay up to a maximum of $456 for a pair of custom-made foot orthotics (unless the price is subject to an agreement between a provider association and the NIHB Program). Replacement of custom-made foot orthotics is eligible every two years.

You can check the Guide for MS&E Benefits for more information on who can prescribe and provide custom-made foot orthotics. Providers who are enrolled with NIHB can bill the Program directly. Please contact the NIHB Program at your Health Canada regional office for assistance finding an enrolled provider.

General Information

Provider Billing and Client Reimbursement

Many providers are enrolled with NIHB and paid directly by the Program, so clients do not have to pay out of pocket for eligible benefits. NIHB recommends that before you receive any item or service, you should confirm with the provider that he or she is enrolled with NIHB and will bill the Program directly, that the item or service is fully covered by NIHB, and that the provider will not charge you any additional fees.

If you are planning to pay up-front for benefits and then seek client reimbursement from NIHB, you should contact NIHB before purchasing items or receiving services to confirm that:

  • The provider is recognized by NIHB and eligible to provide the product or service;
  • The requested item/service is eligible for coverage under the NIHB Program;
  • Whether prior approval is required for coverage; and
  • The provider's rate for the product or service is fully covered by NIHB.

Transition to Department of Indigenous Services

The Government of Canada recently announced plans to create a new department of Indigenous Services. Bringing Indigenous programs and services together in one department will help us to address the key building blocks of Indigenous wellness, together with our partners, in a more coordinated and effective way.

As part of this change, it is expected that programs and services currently delivered by the First Nations and Inuit Health Branch (FNIHB) of Health Canada, including NIHB, will become part of the new department of Indigenous Services in the future. Engagement has been initiated regarding this upcoming transfer.

We want to assure you that services to NIHB clients will not be affected during this transition. The NIHB Program continues to operate 'business as usual', and our contact information remains the same until further notice. If you have any questions, please contact us at NIHB-SSNA@hc-sc.gc.ca.

September 2017

Pharmacy Benefit Information

Celecoxib Coverage Status

Celecoxib (Celebrex and generics) is an anti-inflammatory medication that is used to treat arthritis and other conditions. On July 5, 2017, the NIHB Program changed the coverage status of celecoxib to an open benefit medication. Claims for open benefits are processed automatically and do not require prior approval. Previously, this was a limited use benefit with criteria.

Reduction of Dose Limit for Opioids

Opioids are b pain medications used to treat acute or chronic pain. On November 6, 2017, NIHB will lower the dose limit for opioid medication coverage. The Program is gradually lowering this limit to align with Canadian guidelines and ensure client safety. This does not apply to clients who are taking opioids for cancer or palliative pain management.

Client Eligibility for Naloxone

Naloxone is an injectable medication that can reverse the effects of an overdose from opioid drugs (e.g. heroin, morphine, fentanyl). Health Canada encourages those at risk of an opioid overdose, and people close to them, to have a naloxone kit and the training to use it.

Naloxone is covered by NIHB as an open benefit, and can be prescribed or recommended by a pharmacist. It may be requested for your personal use, or to protect an at-risk person. You do not have to specify who it is for; however, it must be billed to the NIHB Program under the name of the eligible client who is requesting it (even if it is not for their personal use).

Naloxone kits and training may also be available through local or regional public health services.

Dental Benefit Information

Fluoride Varnish

Topical fluoride treatments are applied directly to the teeth to strengthen enamel and help prevent tooth decay. The NIHB Program covers several types of fluoride treatments for children and youth (gel, foam, rinse or varnish); however, evidence shows that fluoride varnish is the most effective. As of July 1, 2017, the NIHB Program provides specific coverage for fluoride varnish at a higher fee compared with other types of fluorides, to encourage the use of this type of topical fluoride treatment.

The NIHB Program covers one (1) fluoride treatment in any six (6) month period for clients 16 years of age and under. A predetermination (PD) is not required.

Clarification on the Age Limit for Sealants and Preventive Resin Restorations

NIHB would like to clarify the new age limit for sealants and preventive resin restorations that was announced in the June 2017 newsletter. The article should have stated that effective June 23, 2017, the NIHB Program increased the age limit to 17 years of age and under for these services.

Medical Supplies and Equipment (MS&E)

Coverage Change for Wound Care Supplies

As of September 11, 2017, prior approval will no longer be required for certain types of wound care supplies. Prior approval will only be required for requests above the maximum amounts or prices, or for specialized wound care supplies.

You can find more information on coverage of wound care supplies in Section 2.0 of the NIHB Medical Supplies and Equipment Benefit List.

General Program Information

Indian Status Card and NIHB Client Eligibility

In order to submit benefit claims to NIHB, service providers require your NIHB client identification number. If you are a registered First Nations person, providers may ask to see your Indian status card because your Indian status registration number also serves as your NIHB client identification number.

An eligible First Nations NIHB client should not be denied services because the renewal date on their status card has passed. Service providers can still use your status registration number to verify your eligibility when submitting NIHB claims. Providers can also call Express Scripts Canada to verify client eligibility for dental, pharmacy and MS&E benefits. For all other benefits, contact NIHB at the regional Health Canada office to verify your eligibility.

If the renewal date on your status card has passed (or is about to), you should renew your card as soon as possible. Application forms and office locations can be found on the Indigenous and Northern Affairs Canada web site and further information is available by calling 1-800-567-9604.

Important Message for NIHB Clients Evacuated Due to Manitoba Forest Fires

If you need to refill or replace items that were covered by the NIHB Program, here is the information you need to know.

Medications

If you need to replace or refill a prescription for medication, please contact one of the following: your assigned Red Cross Coordinator, Grand Medicine Pharmacy at 204-885-0768, or Muskehki Pharmacy at 204-789-3030 (select #4) or toll-free 1-877-544-5521. If possible, please be ready to provide details of your prescription or medication. If you don't know the details of your medication, the pharmacist may be able to look it up for you, or they can call the NIHB Drug Exception Centre.

Dental items (e.g. dentures)

Please contact the NIHB Dental Predetermination Centre at 1-855-618-6291 or the Manitoba Regional NIHB Dental Unit at 1-866-908-9320.

Medical supplies and equipment, vision care (including eyewear), and mental health counselling

Please contact the NIHB Regional Office in Manitoba at 1-800-665-8507.

Medical Transportation Referral Unit (TRU) call centre

NIHB in the Manitoba region has a medical transportation call centre that provides 24-hour service and can be reached at the following toll-free number: 1-877-983-0911.

June 2017

Medical Transportation

Escorts for Pregnant Women

The NIHB Program has expanded the medical transportation benefit to ensure that all pregnant women who require transportation outside the community to deliver their babies are eligible for an escort.

To find out more, contact the Medical Transportation Coordinator in your community or contact NIHB at your Health Canada regional office.

Pharmacy Benefit Information

Medications for Treatment of Hepatitis C

The NIHB Program has added new medications for the treatment of chronic hepatitis C. To improve access, the Program has also expanded the coverage criteria so that more clients can obtain these treatments. Effective March 31, 2017, the NIHB Program covers the following medications as limited use (LU) benefits:

  • Harvoni (ledipasvir/sofosbuvir)
  • Sovaldi (sofosbuvir)
  • Epclusa (sofosbuvir/velpatasvir)
  • Zepatier (elbasvir/grazoprevir)
  • Daklinza (daclatasvir)
  • Sunvepra (asunaprevir)
  • Ibavyr (ribavirin)

The expanded coverage criteria for these medications can be found in the NIHB Drug Benefit List. If you have been diagnosed with hepatitis C, talk to your health care provider about your treatment options.

Infliximab for Treatment of Autoimmune Conditions

Infliximab is a type of medication used to treat some autoimmune conditions and diseases, such as rheumatoid arthritis, Crohn's disease and psoriasis. Previously, the only infliximab product reimbursed by NIHB was Remicade. NIHB has recently listed a second infliximab product, called Inflectra. Inflectra is 'bio-similar' to Remicade, which means that studies have shown these medications work in the same way, and have similar effectiveness.

Effective May 1, 2017, adult clients with new prescriptions for an infliximab medication, who meet NIHB's coverage criteria, will be covered for Inflectra (instead of Remicade). Clients who are already taking Remicade will continue to be covered for their current medication.

NIHB coverage for infliximab follows recommendations from the national Common Drug Review Process (CDR), which reviews medical evidence and provides recommendations to public drug benefit plans and programs in Canada. The CDR has recommended that Inflectra should be covered because this product is similarly effective and has a lower cost, compared to other infliximab medications.

Dental Benefit Information

Frequency Change for Scaling and Root Planing for Children

Frequency Change for Scaling and Root Planing for Children
Effective April 1, 2017, the NIHB Program has changed the frequency of coverage for scaling and root planing for children 0 to 16 years of age.
Previous frequency New frequency
0-11 years 0.5 unit in any 6 month period 1 unit in any 12 month period
12-16 years 1 unit in any 6 month period 2 units in any 12 month period

Dental scaling is a procedure done to remove plaque from a tooth's surface, just below the gumline. Root planing is a procedure done deeper under the gumline to clean the surface of the root of the tooth.

Dental providers bill for these services based on units of time; one unit is equivalent to fifteen minutes of time. The number of units eligible annually has not changed, however the frequency period has changed from 6 months to 12 months to allow providers and clients more flexibility to provide the service as needed.

Predetermination is not required for services provided within these frequency guidelines. For additional units above the annual maximum, a predetermination (PD) is required.

Increased Coverage for Sealants and Preventive Resin Restorations

Effective June 23, 2017, the NIHB Program will increase its coverage for sealants and preventive resin restorations (which are thin plastic coatings applied on the chewing surface of the tooth to prevent tooth decay):

  • Coverage for sealants and preventive resin restorations has been extended to include bicuspids.
  • The age limit for coverage of these services has been increased from 14 to 18 years of age.
  • There is a lifetime limit of 2 sealants/preventive resin restorations per eligible tooth.

The Dental Benefits Guide will be updated to reflect these changes. Please refer to the most recent version of the Guide for a complete listing of dental benefits and policies.

Reminder – Submitting Dental Benefit Appeals

To avoid delays in processing your dental benefits appeal, and to ensure confidentiality of the information provided, please remember to label your envelope and your appeal letter "APPEAL-CONFIDENTIAL". More information on the NIHB dental appeal process can be found on Health Canada's website.

Medical Supplies and Equipment

Frequency Change for Hearing Aid Battery Coverage

Effective June 19, 2017, clients may receive up to 24 batteries every 144 days (previously, the Program covered up to 15 batteries in 90 days). Hearing aid batteries are available in different package sizes, so this change allows for more flexibility to use larger package sizes.

Increased Reimbursement for Custom-Made Foot Orthotics

The NIHB Program has recently increased the reimbursement rate for a pair of custom-made foot orthotics and will now pay up to a maximum of $456.30 (unless the price is otherwise subject to an agreement between a provider association and the NIHB Program). You can check the Guide for MS&E Benefits for more information on who can prescribe and provide custom-made foot orthotics.

As a reminder, prior approval is not required for a pair of custom-made foot orthotics because this requirement has been temporarily lifted until October, 2017. Replacement of custom-made foot orthotics is eligible every two years. If you are not sure of the date you are eligible for replacement, ask your provider to contact Express Scripts Canada, or you can call NIHB at the Health Canada regional office to confirm your eligibility.

Provider Charges for Medical Supplies and Equipment Benefits

Many providers of MS&E benefits are enrolled with NIHB and are paid directly by the Program for eligible products and service provided to NIHB clients. When providers enrol with the Program, they sign an agreement which states that they will not charge any additional fees to NIHB clients.

To avoid out-of-pocket charges, NIHB recommends that you contact your MS&E provider before you receive an item or service to confirm that the provider is registered with NIHB and will bill the Program directly, that the item or service is fully covered by NIHB, and that the provider will not charge you any additional fees.

March 2017

Pharmacy Benefit Information

New Treatments Initiated by Pharmacists

To improve client access to benefits, NIHB has added new products and medications to the list of non-prescription (over-the-counter) benefits that can be prescribed or recommended by pharmacists:

  • Acne medications
  • Medications to treat eye or ear infections
  • Vitamin D or multi-vitamins for children
  • Treatments for fungal skin infections
  • Diabetes devices
  • Blood glucose test strips

You can find a complete list of eligible products and medications that can be prescribed or recommended by pharmacists in the NIHB Pharmacy Benefit Guide.

Reduction of Dose Limit for Opioids

Opioids are b pain medications used to treat acute or chronic pain. On January 3, 2017, NIHB lowered the dose limit for opioid medications. The Program is gradually lowering the opioid dose limit to align with Canadian guidelines and ensure client safety. This does not apply to clients who are taking opioids for cancer or palliative pain management.

Dental Benefit Information

Updated NIHB Dental Benefits Guide

The NIHB Dental Benefits Guide has been updated and is now available on Health Canada's website. The Guide explains dental benefit coverage provided by the NIHB Program, and is a great resource for clients and providers of dental services.

Medical Supplies and Equipment

Updated Medical Supplies and Equipment Benefits Guide

NIHB has updated the benefit guide for medical supplies and equipment. This document used to be called the "Provider Guide for MS&E Benefits", and has now been renamed the "Guide for MS&E Benefits" because it provides both clients and providers with important information about benefit coverage and policies. The updated guide is available on Health Canada's website.

Reminder - Wheelchair Repairs

The NIHB Program covers maintenance and repairs to wheelchairs that were provided through NIHB. Only the most recently purchased wheelchair qualifies for the coverage of repairs when the warranty has expired. Repairs are to restore the wheelchair's physical condition, allowing for normal wear and tear, as noted in the Guide for MS&E Benefits.

Wheelchair repairs require prior approval, must include a warranty according to industry standards, and should be done by a provider who is enrolled with the Program. No prescription is required.

Recognized Providers of Custom-Made Foot Orthotics

NIHB requires that providers have certain types of specialty certification to provide custom-made foot orthotics. Claims for items provided by non-eligible providers will not be reimbursed. Before you get custom-made foot orthotics, make sure that your provider is eligible to provide these benefits under the Program. You can check the Guide for MS&E Benefits for more information on who can prescribe and provide custom-made foot orthotics.

New Options for Hearing Aids

Federal health benefit plans, including NIHB, have an agreement with hearing aid manufacturers. The list of hearing aids available for coverage through this agreement has recently been expanded. Your audiologist, audio-prosthetist or hearing instrument practitioner can provide you more information on the hearing aids available for coverage by the NIHB Program.

General Program Information

Coordination of Benefits with NIHB

Many people have health coverage under more than one benefit plan - for example, you may have benefit coverage through your employer as well as through the NIHB Program. If this is the case, you can take advantage of both plans when claiming expenses. Claims should be submitted to your other plan first, and NIHB will coordinate payment for eligible benefits.

If you have new benefit coverage under another health insurance plan, be sure to inform your pharmacist, dentist or other health care provider. Provide the name of the plan and your policy number so that they can update your file and submit claims in the right order.

You may wish to contact your other plan to get more information about your coverage. If your other plan will not process your claim as first payer, you may be asked to provide written notification to NIHB such as a letter or policy statement from the other plan.

If you no longer have other health benefits coverage, for example if you changed jobs and are no longer covered through another health plan, please let the NIHB Program know as soon as possible by contacting your Health Canada regional office or the Dental Predetermination Centre (for dental benefits only), so that we can update your file and avoid delays in processing future claims.

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