Non-Insured Health Benefits Program Updates

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

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 strong 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 strong 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 strong 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.

December 2016

Pharmacy Benefit Information

Reminder - Emergency Supply of Medications

The NIHB Program would like to remind clients of the emergency supply process that allows pharmacy providers to immediately dispense a short course of medication (up to 4 or 7 days' supply, depending on the province or territory) to treat serious and urgent health conditions, such as antibiotics or medication to prevent blood clotting after surgery.

Most medications covered by NIHB are open benefits. Prescriptions for open benefit medications can be filled without prior approval. For other medications requiring prior approval, the pharmacist must contact the NIHB Drug Exception Centre (DEC). The DEC may need to contact your doctor if more information is required for prior approval.

If your pharmacist says they are unable to fill an urgent prescription because they have to wait for prior approval, please remind them about NIHB's emergency supply process. Your provider can call the DEC and ask them to authorize an emergency dispense during normal business hours (Monday to Friday from 8:00 AM to 6:00 PM in all time zones). If the DEC is closed, providers can still dispense an emergency supply, and contact the DEC on the next business day to request a back-dated approval.

For more information, you can consult the Provider Guide for Pharmacy Benefits, Section 3.6 Emergency Supply Process.

Dental Benefit Information

Coverage Change for Root Canals on Second Molars

As of December 9, 2016, the NIHB Program will no longer require a predetermination (prior approval) for standard root canal treatments on second molars. This means that, if you need a root canal on a second molar and the service is within the Program policy requirements (such as frequency, tooth condition), your dentist can do the procedure as soon as possible and send the claim directly for payment. With this change, NIHB has removed the predetermination requirement for standard root canals on most teeth (with the exception of wisdom teeth).

You can find more information on the NIHB Endodontic (Root Canal) Policy in the Dental Benefits Guide.

Medical Supplies and Equipment

Coverage Change for a Pair of Custom-Made Foot Orthotics

The NIHB Program has made changes that will make it easier for clients to access custom-made foot orthotics. Starting October 17, 2016, a prior approval will not be required for a pair of custom-made foot orthotics because this requirement is temporarily lifted for a trial period of one year. The NIHB Program will pay up to a maximum of $450.00* for a pair of custom-made foot orthotics, and covers replacements of custom-made foot orthotics every two years.

The provider can bill NIHB directly if they are enrolled with the Program. You may be required to pay up-front if the provider is not enrolled, or if you have coverage with another health plan. The Program maximum of $450.00 also applies to client reimbursement requests which are to be sent to your Health Canada regional office. If you have coverage with another plan, please provide the statement of benefits paid by your plan and NIHB may cover the remaining amount (up to the maximum Program coverage).

Note that a prior approval will continue to be required on a single custom-made foot orthotic, as well as repairs, early replacements, and requests for additional coverage. You can contact your Health Canada regional office for more information about these changes.

*(Unless the price is otherwise subject to an agreement between a provider association and the NIHB Program.)

Hearing Aid Coverage Rates

NIHB Program rates for coverage of audiology products (hearing aids) are now published on the Health Canada website. These are the maximum amounts that may be reimbursed for the listed items.

Along with other federal health benefit plans, NIHB has negotiated with manufacturers for special pricing of hearing aids. NIHB maximum rates include the wholesale cost of the hearing aid, plus a set fee for providers to assess, fit and dispense the item.

Hearing aid providers who are enrolled with NIHB can seek prior approval for these items and bill the Program directly so that clients do not pay out of pocket. Clients are strongly encouraged to use an enrolled provider who will be aware of the pricing model for hearing aids, and bill the program at these rates.

If you are planning to purchase a hearing aid from a provider who is not enrolled with NIHB and submit a claim for client reimbursement, you should first contact your Health Canada regional office to make sure that you are aware of coverage rates and criteria. Let the provider know that you are an NIHB client who is eligible for federal health plan rates for hearing aids. If a provider is not enrolled with NIHB and does not know that you are an NIHB client, you may be charged a retail price that is higher than the maximum amount that will be reimbursed by NIHB.

Vision Care Benefit Information

New Coverage for Progressive Lenses

The NIHB Program is pleased to announce new coverage for progressive bifocal lenses.

When a client needs correction for close and distance vision, this may be combined into one pair of glasses using either standard bifocal or progressive lenses. In a standard bifocal lens, the two areas of vision correction are divided by a visible horizontal line. The progressive lens is simply a 'no-line' bifocal. Progressive lenses for close and distance vision correction are now eligible benefits, and may be reimbursed up to the same rate and using the same criteria as standard bifocal lenses.

Clients are responsible for any upgrades over the maximum coverage rates. For more details on the minimum requirements for eyewear coverage, please consult the NIHB Vision Care Benefit List.

September 2016

Pharmacy Benefit Information

2016 NIHB Drug Benefit List

The 2016 NIHB Drug Benefit List (DBL) is now available on the Health Canada website. The DBL lists medications and products that are eligible for NIHB coverage. More than 50 listings have been added as new NIHB benefits, including:

  • Invokana and Jardiance, oral medications used in the treatment of Type 2 diabetes
  • Fosrenol, a medication used to lower phosphate levels in patients with end stage kidney disease
  • Simponi, for the treatment of ulcerative colitis

Dental Benefit Information

Frequency Change for Crown Coverage

NIHB has changed its policy for coverage of crowns, and will now cover up to 4 crowns in a 10 year period (instead of 1 in 3 years). This change allows more flexibility to provide crowns when they are needed. The NIHB crown policy continues to apply.

The Program will continue to review requests for additional coverage of crowns and may make exceptions in special cases, such as an accident resulting in trauma to the mouth.

Medical Supplies and Equipment

Client Reimbursement for Medical Supplies and Equipment Benefits

Many providers of MS&E benefits are enrolled with NIHB and are paid directly by the Program. To avoid out-of-pocket charges, NIHB recommends contacting your MS&E provider before receiving any item to confirm that the provider is registered with NIHB to bill the Program directly, that the item is fully covered by NIHB, and that the provider will not charge you any additional fees.

However, if you are planning to pay up-front for MS&E benefits and then seek client reimbursement from NIHB, you should contact the Health Canada regional office before purchasing items or receiving services to make sure 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
  • The provider's rate for the product or service will be fully covered by NIHB

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.

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.

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 by contacting your Health Canada regional office as soon as possible so that we can update your file and avoid delays in processing future claims. If you still have other coverage but the other plan will not coordinate benefits with NIHB, you may be asked to provide written notification such as a letter or policy statement from the other plan.

June 2016

Pharmacy Benefit Information

Change in the Listing Status of Bisphosphonates

Bisphosphonates are drugs that help strengthen bones, and are used in the treatment and prevention of osteoporosis and Paget disease. On March 10, 2016, oral bisphosphonate medications covered by the NIHB Program became open benefits. Claims for open benefits are processed automatically and do not require prior approval.

New Treatments Initiated by Pharmacists

Effective June 1, 2016, NIHB expanded options for pharmacists to initiate treatments for NIHB clients. These will allow easier access to many eligible products and medications. NIHB will accept prescriptions or written recommendations from pharmacists for claims that do not require prior approval, for the following types of benefits:

  • Prenatal vitamins
  • Medications for the prevention and treatment of nausea and vomiting in pregnancy
  • Emergency contraception ( the 'morning after pill')
  • Vaginal yeast infection treatments
  • Smoking cessation aids
  • Lice treatments
  • Allergy medications
  • Constipation treatments
  • Naloxone

Please remember that each province and territory has different regulations for health care providers, so you should talk to your local pharmacist to find out whether they can recommend or prescribe these treatments for you.

Coverage for Naloxone

Naloxone is an injectable medication that can reverse the effects of an overdose from opioid drugs (e.g. heroin, morphine, fentanyl). To improve access to this life-saving medication, NIHB has added naloxone as an open benefit on the Drug Benefit List.

If you or someone close to you may be at risk of an opioid overdose, it is recommended that you have a naloxone kit on hand, and be trained to use it. Public health programs in some provinces and territories now provide naloxone kits and training, so before claiming it through NIHB, you should check with your pharmacist to see if it is available through local health services.

Reminder - Change in Coverage of Medications to Treat Constipation

Docusate is a stool softener that may be prescribed for constipation. However, recent medical studies have found that docusate is not an effective medication to prevent or relieve constipation. Effective September 13, 2016, docusate products will not be covered by NIHB.

I'm taking stool softeners - now what do I do?

There are many different ways to treat constipation. Changes to your diet and how much physical activity you are getting may help, but sometimes medication is needed.

NIHB covers many other medications for constipation that are effective. Some of these work by making your stool bulkier and easier to pass. Others work by stimulating your bowels to move. Some draw water into you bowel making it easier to pass stools. Still others lubricate your bowel so that stool moves more easily through them. These medications come in many different forms: pills, liquids, powders, suppositories (that are inserted into the rectum), and enemas (fluid inserted through the rectum).

NIHB will pay for alternate treatments when prescribed or recommended by your pharmacist, nurse practitioner, physician, or other prescriber. Together with your healthcare provider, you can choose a treatment covered by NIHB that is right for you.

Where can I find more information?

For more information about coverage of other medications for constipation, consult the NIHB Drug Benefit List. You can review the evidence on stool softeners and other treatments for constipation at Canadian Agency for Drugs and Technologies in Health (CADTH).

Dental Benefit Information

NIHB Welcomes Dental Hygienists as Independent Service Providers

Effective June 1st, 2016, dental hygienists are able to submit claims to the Program as independent service providers, within their professional scope of practice. This applies in all regions except Quebec, Prince Edward Island, and the Territories, where professional regulations do not currently allow dental hygienists to practice independently.

NIHB welcomes dental hygienists to the Program, and is pleased to notify clients of this change that increases access to preventive oral health care for First Nations and Inuit.

May 2016

Important Message for NIHB Clients Evacuated Due to Alberta 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 go to a local pharmacy and identify yourself as an NIHB client. If possible, please bring a copy of your prescription or medication packaging. If you don't know the details of your medication, your 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.

Medical supplies and equipment and eyewear

If you are in Alberta or BC, please contact the NIHB Regional Office in Alberta at 1-800-232-7301.

If you have been relocated outside of Alberta, contact the NIHB Regional Office in the province where you currently are.

Medical transportation call centre

NIHB in the Alberta region has a medical transportation call centre that provides 24-hour service:

  • Telephone: 780-495-2708
  • Toll free: 1-800-514-7106

Mental health counselling

This benefit is intended to provide coverage for immediate psychological and emotional care to individuals in significant distress to stabilize their condition, minimize potential trauma from an acute life event, and, as appropriate, transition them to other mental health supports.

For assistance accessing mental health counselling, NIHB clients in Alberta should call:

  • Telephone: 780-495-3302
  • Toll free: 1-800-232-7301

March 2016

Pharmacy Benefit Information

Change in Coverage of Medications Used to Treat Constipation

Docusate is a stool softener that may be prescribed for constipation. However, recent medical studies have found that docusate is not an effective medication to prevent or relieve constipation. These findings were reported by the Canadian Association for Drugs and Technologies in Health (CADTH), an independent organization that provides research and information about the effectiveness of drugs and other medical treatments.

Because of this evidence, the NIHB Drugs and Therapeutics Advisory Committee (DTAC) recommended changing the listing status of docusate to non-benefit. Effective September 13, 2016, docusate products will not be covered by NIHB.

However, the NIHB Program covers many other products which are proven effective for the prevention or treatment of constipation. If you are taking a docusate medication, please talk to your health care provider about a different treatment option that is covered by NIHB.

Dental Benefit Information

Frequency Change for Plastic Partial Dentures

As of January 4, 2016, the NIHB Program has increased coverage for partial plastic (acrylic) dentures. NIHB will now consider coverage for replacement every 5 years (instead of every 8 years). The NIHB Dental Benefits Guide will be updated to reflect this change.

These tips will help to keep your plastic partial dentures comfortable and functional:

  • Rinse your mouth and dentures following meals to reduce staining and debris build-up on your dentures.
  • Remove dentures when you are sleeping so that your gums have a chance to 'breathe'.
  • Always keep plastic dentures in water when you have removed them for more than a few hours. Otherwise they will dry out, and crack more easily.
  • Never bite a partial denture into place in your mouth. Always place it with your fingers. Your jaws are very strong, and if the partial denture is not in exactly the correct position when biting, it can be damaged or your mouth can be injured.

Medical Supplies and Equipment Information

MS&E Northern Region Contact Information

Health Canada has two offices for the Northern Region: one in Ottawa, and the other in Whitehorse. The Northern Region office in Ottawa has a new address, and now manages MS&E benefits for all 3 territories. Clients from the Yukon, Nunavut or Northwest Territories who need to contact NIHB about MS&E (general inquiries or client reimbursements) may contact NIHB at the following telephone number and mailing address:

Telephone: 1-888-332-9222

Non-Insured Health Benefits
Northern Region, Health Canada
Tupper Building
2720 Riverside Drive, 4th Floor
Address Locator: 6604C
Ottawa, Ontario
K1A 0K9

Client Reimbursement for MS&E Items

If your MS&E provider is enrolled with NIHB, he or she should seek prior approval and bill NIHB directly for MS&E benefits. In some circumstances, such as when you are coordinating benefits with another health plan, or if your service provider is not enrolled with NIHB, you may have to pay up front for MS&E items. NIHB recommends contacting your MS&E provider in advance to ask whether the provider is registered with NIHB, and will bill the Program directly for items provided to you.

NIHB reimbursement will only be approved if the item is an eligible benefit and if you meet NIHB coverage criteria for the item. If you are paying up front for an MS&E item without prior approval, you should contact your Health Canada regional office to verify that the item is eligible for coverage.

When the cost of an MS&E item is fully covered through another public or private health care plan, and you have coverage through this plan, the NIHB Program will not approve requests for co-payment to upgrade the item. Client reimbursement will not be provided if you choose to pay out-of-pocket for the upgrade.

General Program Information

NIHB Navigators

NIHB Navigators help eligible clients to 'navigate' and access the NIHB Program. They are a resource for communities, organizations or individuals who need support or information on NIHB-related issues. Navigators are employed by regional First Nations organizations. Their roles and activities are adapted to meet regional needs, and generally include the following:

  • Increase understanding of the NIHB Program and share information on eligible benefits;
  • Help clients and communities to resolve NIHB-related issues;
  • Link with health departments and agencies to help improve client access to NIHB benefits and related health services.

More information about NIHB Navigators, including contact information, can be found on the Assembly of First Nations website.

January 2016

Dental Benefit Information

Preventive Dental Care

Preventive dental care includes taking good care of your teeth in order to prevent cavities, gum disease and other oral health problems. Regular brushing and flossing, eating a healthy diet, and visiting the dentist regularly are the most important things you can do to keep your mouth healthy.

The NIHB Program covers preventive dental services for adults and children. Children under 17 years of age are eligible for dental checkups, fluoride treatment and cleaning every six months. Clients 17 years of age and over are eligible for dental checkups and cleaning once a year.

It is recommended that children visit the dentist within six months of their first tooth coming in. Please check the NIHB Dental Benefits Guide for a complete list of eligible dental services and treatments.

General Program Information

Reminder for Parents and Guardians of NIHB-Eligible Infant Children

Parents and guardians of infant children are encouraged to apply for registered Indian status or seek recognition from their Inuit land claims organization as soon as possible to ensure their child's access to NIHB benefits. In order to allow parents time to register their children, infants up to one year of age may access most types of NIHB benefits under their parent or guardian who is NIHB eligible. After their first birthday, a child should have his or her own status or N number to ensure continued eligibility for NIHB benefits. For additional information visit the following section of the NIHB web site: To register an infant. For dental services only, contact the NIHB Dental Predetermination Centre if dental services are required for an unregistered infant under one year of age.

NIHB Registered Providers

Did you know that the NIHB Program works with over 30,000 private practice health service providers - such as dentists, pharmacists, optometrists and mental health counsellors - to help NIHB clients get the health benefits they need?

NIHB invites health service providers to register with the Program so that NIHB can pay them directly for eligible products and services provided to NIHB clients. These health service providers are not employees of Health Canada or the NIHB Program (with a few exceptions). NIHB has agreements with providers that encourage them to bill the Program directly, however in some cases providers will request that clients pay up front for their health benefits and services. To avoid an unexpected bill, it's best to confirm with your provider that they are registered with NIHB and will bill the Program directly, and that the product or service is fully covered by NIHB.

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