Guide for pharmacy benefits for First Nations and Inuit: Non-Insured Health Benefits

Effective date: December 13, 2023

This guide provides information on Indigenous Services Canada's Non-Insured Health Benefits (NIHB) program for eligible First Nations and Inuit and its policies relevant to pharmacy benefit coverage. It explains the extent and limitations of the NIHB program's pharmacy benefits by describing the important elements of each associated policy. It also lists website addresses to provide quick access to related forms and more detailed program information.

Refer to the Pharmacy Claims Submission Kit, available on the Express Scripts Canada NIHB provider and client website, for the process to submit claims for payment of goods and services rendered to eligible clients.

Table of contents

1.0 Introduction

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Indigenous Services Canada's Non-Insured Health Benefits (NIHB) program is a national program that provides eligible First Nations and Inuit with coverage for a range of medically necessary health benefits when these benefits are not otherwise covered through private, provincial, or territorial health insurance plans or social programs.

NIHB program benefits include prescription drugs and select over-the-counter (OTC) medications, dental and vision care, medical supplies and equipment, mental health counselling, and transportation to access medically required health services that are not available on reserve or in the community of residence.

As pharmacy benefit policies and procedures evolve, this guide is updated accordingly and providers are advised of these changes through the NIHB newsletters and NIHB bulletins distributed by Express Scripts Canada and available on the Express Scripts Canada NIHB provider and client website. Clients are advised through the NIHB program updates.

Providers are advised to refer to the most current version of the guide as well as NIHB newsletters, available on the Express Scripts Canada NIHB provider and client website, to ensure NIHB program policy requirements are met. In the event of a contradiction between versions of the guide, the provisions of the NIHB program's web-posted guide will prevail.

References to or the use of 'dispensing fee', 'usual and customary dispensing fee', or any variation thereof are subject to reimbursement up to the regional maximum of the program. Pharmacy providers in Quebec should refer to the agreement between Indigenous Services Canada and l'Association québécoise des pharmaciens propriétaires (AQPP) for reimbursement details.

1.1 Terms and conditions of services

To be eligible for payment, providers must adhere to the NIHB program's terms and conditions. These are detailed within the NIHB Billing Agreement (available within the NIHB Pharmacy Provider Enrolment Package) and the Pharmacy Claims Submission Kit, both available on the Express Scripts Canada NIHB provider and client website.

It is the pharmacist's responsibility to verify benefit eligibility for the client, at the time of dispensing, to ensure that no limitations under the program will be exceeded, and to ensure compliance with NIHB benefit criteria and policies.

2.0 Benefit description and conditions

The pharmacy, or drug component, of the NIHB program covers drugs and other eligible health products that are included on the Drug Benefit List, available on the Express Scripts Canada NIHB provider and client website. These products must be prescribed or recommended by a health professional as defined in section 3.12 Prescriber policy for pharmacy benefits, licensed to prescribe in a given jurisdiction.

Eligible pharmacy benefits are based on policies established with guidance from NIHB's Drugs and Therapeutics Advisory Committee (DTAC), Health Canada, and Canadian Agency for Drugs and Technologies in Health (CADTH), to provide eligible clients with access to benefits not otherwise available under federal, provincial, territorial, or private health insurance plans.

Pharmacy benefits are covered in accordance with the mandate of the NIHB program. This includes 'open benefits' which are listed on the Drug Benefit List and do not require prior approval, and 'limited use benefits' which are on the Drug Benefit List and may be eligible for coverage if the criteria for coverage are met.

Clients of the NIHB program do not pay deductibles or co-payments.

2.1 Drug Benefit List

The NIHB program maintains a formulary called the Drug Benefit List which includes eligible drugs and other health products primarily used in a home or ambulatory setting. The Drug Benefit List is posted online on the Express Scripts Canada NIHB provider and client website and changes made to it will be communicated via newsletters and bulletins on that website. The Government of Canada website will also periodically be updated with NIHB program updates.

A prescription or recommendation from a health professional as defined in section 3.12 Prescriber policy for pharmacy benefits is required for any listed drug or eligible health product to be processed as a benefit under the NIHB program.

Items considered for, or currently listed on, the Drug Benefit List must meet the minimum criteria. They must be legally available for sale in Canada with a Notice of Compliance. They must also demonstrate evidence of therapeutic efficacy, safety, and incremental benefit in proportion to the incremental cost.

Decisions on drug benefits are based on the judgment of recognized health professionals, consistent with the best practices of health services delivery and evidence-based standards of care.

The review process for drug products that are considered for inclusion as a benefit under the NIHB program varies depending on the type of drug submitted.

Submissions for new chemical entities, new combination drug products and existing chemical entities with new indications must be sent to the Canadian Agency for Drugs and Technologies in Health (CADTH). Clinical and pharmacoeconomic reviews are coordinated by the Common Drug Review (CDR) Directorate and forwarded to the Canadian Drug Expert Committee (CDEC) for recommendations on formulary listing. These recommendations are forwarded to participating drug plans, including the NIHB program, for consideration. The NIHB program and other drug plans make listing decisions based on CDEC recommendations and other specific relevant factors, such as mandate, priorities, client safety and resources.

Submissions for line extensions, generics and all other submissions are reviewed internally or by the Drugs and Therapeutics Advisory Committee (DTAC). Generic drug products are considered for inclusion on the formulary based on provincial interchangeability lists and other relevant factors.

Should you have any questions regarding the Drug Benefit List, please contact the NIHB Call Centre at Express Scripts Canada toll-free 1-888-511-4666 for providers.

2.2 Open benefits

Open benefits are items listed on the Drug Benefit List, available on the Express Scripts Canada NIHB provider and client website, which do not have established criteria, age limitations, or prior approval requirements. This means that, in most cases, pharmacy providers may submit claims for dispensing open benefit items without receiving prior approval requirements.

Open benefits may include specific eligible items in the following categories:

  • prescription drugs
  • over-the-counter medications
  • injectable drugs, including injectable allergy serums
  • extemporaneous mixtures
  • drug delivery devices, as required, to deliver medications for certain conditions
  • recognized non-oral contraceptive devices
  • therapeutic vitamins and minerals

2.3 Limited use benefits

Limited use benefits are products listed on the Drug Benefit List, available on the Express Scrips Canada NIHB provider and client website, that may not be appropriate for general listing, but have value in specific circumstances. These products will have specific criteria for provision as a benefit under the NIHB program. A product will be designated for limited use when:

  • it has the potential for widespread use outside the indications for which a health benefit has been demonstrated
  • it has proven effectiveness, but is associated with predictable severe adverse effects
  • it is usually a second or third line choice for treatment and is required because of allergies, intolerance, treatment failure or noncompliance with a first line alternative
  • there is a cost-effective and therapeutically effective alternative available as an open benefit

There are 3 types of limited use benefits:

  1. Limited use benefits which do not require prior approval. These include but are not limited to:
    • multivitamins: which are benefits for clients up to 19 years of age
    • prenatal and postnatal vitamins: which are benefits for women of childbearing age 12 to 50 years
  2. Benefits which have a quantity or frequency limit. A maximum quantity of drug is allowed within a specified period of time. No prior approval is required for the recipient to obtain the allowable quantity of drugs within the specified period.
  3. Limited use benefits which require prior approval using the "Limited Use Benefit Request Form." Prior approval for some limited use benefits may also be obtained automatically for a select group of limited use benefits via the electronic claims adjudication system where a claim is submitted and meets the criteria. Limited use benefits and the criteria for their coverage are identified in the Drug Benefit List, available on the Express Scrips Canada NIHB provider and client website. The criteria are also listed on the forms faxed to prescribers for completion.

2.4 Exceptions

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Exception products are not listed on the Drug Benefit List. These products may be approved in special circumstances upon receipt of a completed Exception Drugs Request Form from the licensed prescriber when:

  • the prescription is for a recognized clinical indication and dose which is supported by published evidence or authoritative opinion
  • there is significant evidence that the requested drug is superior to drugs already listed as program benefits
  • a client has experienced an adverse reaction with a best price alternative drug, and a higher-cost alternative is requested by the prescriber
  • there is supporting evidence that available alternatives are ineffective or contraindicated

Personal preference alone does not justify coverage of an exception.

2.5 Exclusions

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Certain products are excluded from the NIHB program as recommended by the Common Drug Review (CDR), the pan-Canadian Oncology Drug Review (pCODR) and the NIHB Drugs and Therapeutics Advisory Committee (DTAC) because published evidence does not support the clinical value or cost of the item relative to existing therapies, or there is insufficient clinical evidence to support coverage.

Exclusions are items not listed on the Drug Benefit List and not available through the exception or appeal processes. These include certain therapies for particular conditions which fall outside of the NIHB mandate.

Examples of categories of drugs or drug products* that are not considered for coverage under the Program under any circumstances are as follows:

  • anti-obesity drugs
  • household products (for example, regular soaps and shampoos)
  • cosmetics
  • alternative therapies, including glucosamine and evening primrose oil
  • megavitamins
  • investigational or experimental products
  • medications for travel
  • hair growth stimulants
  • impotence drugs
  • opioid containing cough preparations

*Note: List of excluded drugs or drug products is not exhaustive and may be modified as necessary.

2.6 Prior approval

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In addition to limited use benefits, some items not listed on the Drug Benefit List may be considered for coverage under special circumstances, with prior approval.

If a client is prescribed a drug or item that requires prior approval, the provider will receive a message at the point of sale indicating that a special authorization is needed. In these cases, the provider must contact the Drug Exception Centre and provide details about the prescription, prescriber, client and pharmacy. To complete the prior approval process, the Drug Exception Centre may also fax an Exception or Limited Use Benefit Request Form to the prescriber for completion. Providers may also submit claims and prior approval requests through their NIHB web account, found on the Express Scripts Canada NIHB provider and client website.

Certain limited use drugs are automatically reviewed and may be approved electronically when a claim is submitted at point of sale, and the client's medication history meets the program criteria. If a claim is rejected, the provider may contact the Drug Exception Centre to have the approval request reviewed.

Prior approval may also be obtained automatically for a select group of limited use drugs via the electronic claims adjudication system when a claim is submitted and meets the criteria. If rejected, the provider may contact the Drug Exception Centre to have the prior approval request reviewed.

The time that it takes the Drug Exception Centre to review prior approval requests or rejected claims depends on the time it takes for the prescriber to provide any needed information. Providers should be aware that a representative from the Drug Exception Centre may call them directly to discuss the request or to collect any necessary information. When approval is granted, a confirmation letter with the applicable dates and prior approval details will be faxed or mailed to the provider. Pharmacy providers are advised to retain the confirmation letter, if applicable, for billing purposes.

Prior approval for specific benefits does not provide approval for a price change unless also specifically requested. NIHB sets maximum costing limits for specific items. Any price that exceeds the maximum price requires specific and separate approval by NIHB.

Prior approvals are entered electronically in the claims processing system. The date of dispense, if known, should be provided to the analyst so that it can be reflected in the prior approval. When submitting the claim, providers must include the date of service or dispense date.

Please refer to the Pharmacy Claims Submission Kit, found on the Express Scripts Canada NIHB provider and client website, for more information on obtaining prior approvals.

2.7 Formulary for chronic renal failure

Clients with chronic renal failure are eligible to receive a list of supplemental benefits that are not included on the Drug Benefit List but may be required on a long-term basis. These supplemental benefits are provided when provincial or territorial renal programs are not available to NIHB clients.

New clients that require items on the special formulary will be identified for coverage through the usual prior approval process. Once the client is confirmed as eligible, coverage will automatically be extended to all items in the special formulary for as long as needed.

2.8 End-of-life care formulary

Clients who are diagnosed with a terminal illness and are near the end of life will be eligible to receive a list of supplemental benefits that are not included on the Drug Benefit List.

When the Drug Exception Centre is informed that a client requires end-of-life care, an End-of-life care formulary application form will be generated and faxed to the prescriber. Once this form is completed and submitted, the client will be eligible for all medications and nutritional supplements on the End-of-life care formulary if the following criteria are met:

  • the client is not receiving care in a provincially covered hospital or long-term care facility

    AND

  • the client has been diagnosed with a terminal illness or disease which is expected to be the primary cause of death within 6 months or less

Once approved, the client will be eligible for all medications on the End-of-life care formulary for 6 months, without the need for further prior approval. If coverage is required beyond the initial 6 months, an additional 6 months may be granted upon receipt of a new "End-of-Life Care Formulary Application Form" request.

For clients awaiting approval, providers may dispense an initial emergency course of treatment of up to a 14-day supply. For detailed information, see section 3.6 Emergency supply process.

2.9 Formulary for adjunct medications used during active cancer treatment

The NIHB program has established a formulary to streamline access to adjunctive (non-chemotherapy) medications frequently used by clients undergoing active cancer treatment. These clients will be eligible to receive a list of supplemental benefits that are not included on the Drug Benefit List. Clients approved for oral chemotherapy drugs are automatically approved for access to all the medications in this formulary. Additionally, clients approved for 1 of these medications for a cancer-related indication are automatically approved for access to all other medications and nutritional supplements in this formulary.

Clients are automatically enrolled for a period of 6 months. If cancer treatment is of a longer duration, access to the formulary will be granted to align with the treatment duration. If treatment duration is not known, and the treatment plan extends beyond 6 months, access to this formulary may be extended upon request.

2.10 Formulary for medically necessary nutrition products

The NIHB program has established a formulary for clients who require medically necessary nutrition products. The formulary includes the following products: thickening agents, infant formulas and nutritional supplements for children, youth and adults. The program only provides coverage for products that have demonstrated benefit as part of managing a medical condition. For example, variations of these products labelled as "organic" are not included in this formulary.

Nutritional supplements remain as a part of other special formularies, specifically Formulary for chronic renal failure, Formulary for adjunct medications used during active cancer treatment, and End-of-life care formulary.

2.11 Drug Utilization Review Program

A Drug Utilization Review (DUR) Program, which is part of the point of sale or on-line adjudication system, provides an analysis of both previous claims data and current claims data to ensure that providers are advised of potential drug-related problems or interactions. Messages are returned to pharmacists to alert them of the potential problems. The purpose of DUR is not to replace professional judgment or individualized client care in the delivery of healthcare services, but to enhance them with additional information.

For more information on the DUR program, please refer to the Pharmacy Claims Submission Kit available on the Express Scripts Canada NIHB provider and client website.

2.11.1 Intervention codes

When pharmacy providers decide to override a reject message with an intervention code, they must complete and retain the appropriate documentation on the nature of the intervention directly on the prescription or on any hard or electronic version of the client file. To avoid the recovery of claim payment during the claims verification process, proper documentation of any intervention is required. This should include:

  • date of the intervention
  • summary of the intervention by the pharmacy provider
  • documented communication with the prescriber, caregiver or client
  • reason for early refill: medication lost, destroyed, stolen, prescriber changed dosage, or client going out of town for a period greater than the "days supply" remaining of the current refill

2.11.2 Lost medications

In the event a client loses their medication, a provider can use an intervention code to override a drug utilization review reject message for "fill too soon". The prescription or client profile at the pharmacy must contain specific documentation citing the reason the prescription was refilled early.

Pharmacy providers can decide to override a reject message with an intervention code, "MR". They must complete and retain the appropriate documentation on the nature of the intervention directly on the prescription or on any hard or electronic version of the client file. To avoid the recovery of claim payment during the claims verification process, proper documentation of any intervention is required. This may include:

  • date of the intervention
  • summary of the intervention by the pharmacy provider
  • documented communication with the prescriber, caregiver or patient
  • reason for early refill, for example medication lost

2.11.3 Community evacuation

In the event of a community evacuation as a result of a wildfire, flood, etc., affected NIHB clients may not have access to their medications and will require a refill or replacement. If a pharmacy receives a rejection code (ME, MW, MY or NE) when submitting claims for refills or replacements as a result of a community evacuation, please use the most applicable Canadian Pharmacist Association (CPhA) intervention code as outlined in section 7.5.1. CPhA Intervention Codes of the Pharmacy Claims Submission Kit available on the Express Scripts Canada NIHB provider and client website.

2.12 Client Safety Program (NIHB-CSP)

The Client Safety Program (NIHB-CSP) addresses concerns over potential problematic use of prescription medications which include benzodiazepines, opioids, stimulants, gabapentin, pregabalin and nabilone. This includes clients receiving high doses of these medications or prescriptions being obtained through multiple prescribers or pharmacies.

When a client is entered into the NIHB-CSP they are asked to choose a prescriber or group practice to write prescriptions for benzodiazepines, opioids, stimulants, gabapentin, pregabalin and nabilone. This prescriber may become the sole prescriber for 1 or for more of these classes of drugs. Once a prescriber or group practice has agreed to be the client's sole prescriber for these medications, NIHB will cover the cost of those eligible prescriptions, which can be dispensed at any pharmacy.

When the NIHB program covers medication for clients for the treatment of opioid use disorder, such as methadone, buprenorphine/naloxone (Suboxone® and generics), long-acting morphine (Kadian®), buprenorphine (Sublocade®) or other medications, clients are placed in the NIHB-CSP. See section 3.5 Opioid Use Disorder Treatment.

Once the client has been placed in the NIHB-CSP, the next time the client attempts to fill a prescription for benzodiazepines, opioids, stimulants, gabapentin, pregabalin or nabilone, the pharmacy will receive a rejection message and must call the Drug Exception Centre. The Drug Exception Centre will fax the pharmacy a NIHB-CSP package to give to the client.

The pharmacy will be paid a usual and customary dispensing fee for providing the NIHB-CSP package to the client. The pharmacist will be issued a prior approval for pseudo-DIN 91500001 in order to claim the fee.

The dispensing fee will cover the cost of:

  • calling the Drug Exception Centre and speaking to the NIHB representative
  • accepting the faxed documents from NIHB
  • giving the 2 documents plus 1 copy of the Fact Sheet to the client. If the client has difficulty understanding the documents, the pharmacist may explain the document contents and direct the client to call their respective regional office for additional information

Please visit the NIHB Client Safety Program for more information.

2.13 Surveillance of problematic substance use

The NIHB Client Safety Program (NIHB-CSP) has introduced a wide range of client safety measures to prevent and respond to potential problematic use of prescription medications to ensure that First Nations and Inuit clients can get the medications they need without being put at risk. These monitored drugs include benzodiazepines, opioids, stimulants, gabapentin-pregabalin and nabilone. The program has introduced several strategies to monitor these medications which include gradually reducing dose limits, the NIHB-CSP (as described above), and reviewing the utilization of medications prescribed and dispensed for NIHB clients.

3.0 Policies

The following policies affect reimbursement of pharmacy goods and services provided to eligible NIHB clients. As policies and procedures evolve, this guide is updated accordingly. Pharmacy providers are advised of these changes through the program's NIHB newsletters which are available on the Express Scripts Canada NIHB provider and client website.

3.1 Best price alternative

The NIHB program covers the lowest cost equivalent drug, which is often a generic product. Generic products are considered for inclusion on the NIHB formulary based on provincial interchangeability lists and other relevant factors.

The NIHB program will reimburse only the best price (lowest cost) alternative product in a group of interchangeable drug products. Pharmacists must follow their provincial or territorial pharmacy legislation and policies to identify interchangeable products and to select the lowest-priced brand. The program may not necessarily reimburse at the cost listed in the provincial drug plan formulary.

3.1.1 Interchangeability

The NIHB policy to reimburse the best price alternative product also applies to generic products not deemed interchangeable by the province or generic products not listed on the provincial formulary. For these drugs, the NIHB program will only reimburse up to the best price (lowest cost) generic product available in the provincial formulary. If the pharmacist chooses a generic product that is covered by the NIHB program but is not listed on the provincial formulary or interchangeability list, the claim will be reimbursed to the maximum of the provincially listed lowest cost equivalent price and the higher costs will not be reimbursed.

Among interchangeable over-the-counter products, the maximum allowable price will be that of the lowest cost equivalent listed on the Drug Benefit List, available on the Express Scripts Canada NIHB provider and client website.

3.1.2 Maximum allowable cost for over-the-counter medications

The NIHB program has a maximum allowable cost pricing model for select over-the-counter medications. Pricing for medications will be determined through assessments of product accessibility and package sizing by province and territory which will ensure fairness to providers while providing unit cost consistency. For example, all DINs for acetaminophen 500 mg are subject to the same maximum allowable cost price. The over-the-counter maximum allowable cost pricing will be reviewed and updated regularly. Only oral tablets, capsules and caplets are included in the over-the-counter maximum allowable cost pricing model. The products that have a defined over-the-counter maximum allowable cost include acetaminophen (Tylenol®), acetylsalicylic acid (Aspirin®), loratadine (Claritin®), cetirizine (Reactine®), and ibuprofen (Advil®).

3.1.3 Package size

Costing must be based on appropriate package sizing for quantities dispensed in pharmacies. This means that costs submitted by pharmacy providers must correspond to the actual cost for the product incurred by the pharmacy provider and not to costs relative to a package size that is more expensive. All claim submissions will be calculated based on the lowest unit cost.

3.2 "No substitution" claims

The NIHB program will consider reimbursement for a higher-cost interchangeable product when a client has experienced an adverse reaction with a lower-cost alternative. In such circumstances, the prescriber must provide NIHB with:

  • a completed and signed Side Effect Reporting Form: 'Report of suspected adverse reactions to health products in Canada'
  • the prescription indicating "No substitution" or "No sub". Verbal authorization of 'no substitution' is not accepted by NIHB

Upon receipt, the pharmacist will forward a copy of the prescription to NIHB for review. The prescriber is responsible for submitting the form to the Canada Vigilance program. Forms can be obtained by calling the Canada Vigilance program at 1-866-234-2345, by downloading a copy of the Side Effect Reporting Form, or by photocopying a copy from the Compendium of Pharmaceuticals and Specialties.

The Side Effect Reporting Form will not need to be resubmitted for renewals or new prescriptions of the same drug for the client, although a prescription indicating "No sub" will still be required. Verbal authorization of 'no substitution' is not accepted by the NIHB program.

3.3 Prescription quantities

The program reimburses 100-day supply of chronic medications unless otherwise indicated by the prescriber. This ensures that certain medications required for long-term maintenance therapy are prescribed and dispensed efficiently.

The default maximum allowed dollar threshold for claims adjudication without a prior approval is $1999.99. Providers require a prior approval for claims that are over $1999.99. The NIHB program may set a lower maximum dollar threshold for specific items. Providers will be notified of these exceptions. Please contact the NIHB Call Centre at Express Scripts Canada at toll-free 1-888-511-4666 for related questions.

3.3.1 Short-term dispensing

It is the program's expectation that certain medications required for long-term maintenance therapy should be dispensed in up to 100-day supplies. For medication refills requiring short-term dispensing for a shorter duration than 28 days due to compliance concerns, the program will reimburse a total of 1 dispensing fee per 28 days up to the regional maximum of the program. These medications include the following:

  • alpha-adrenoreceptor antagonists
  • anticoagulants
  • anti-dementia drugs
  • anti-gout drugs
  • antihistamines
  • anti-parkinsonian drugs
  • anti-platelet
  • benign prostatic hyperplasia (BPH) drugs
  • cardiovascular drugs
  • drugs for diabetes
  • drugs for treatment of bone diseases
  • enzyme preparations
  • gastrointestinal (GI) anti-inflammatory drugs
  • H2-receptor antagonists
  • immunosuppressants
  • non-steroidal anti-inflammatory drugs (NSAIDs)
  • over-the-counter products (including vitamins)
  • other drugs for peptic ulcer and gastro-esophageal reflux disease (GERD)
  • prokinetic agents
  • proton pump inhibitors
  • synthetic antidiuretic hormone
  • thyroid therapy
  • urinary anti-spasmodics

The following are exceptions to the short-term dispensing policy:

  • refills for intermittent treatment of a chronic disorder or refills of a medication which are prescribed to be taken on an "as needed" (PRN) basis Footnote 1
  • prescriptions for dose changes
  • injectable and suppository dosage forms
  • refills or new prescriptions when prescribed or dispensed in accordance with a court order
3.3.1.1 Compensation

The compensation will be the lesser of the usual and customary fee up to the maximum negotiated NIHB regional dispensing fee for each 28 days supplied. NIHB will continue to monitor and recover via the claims verification program in instances where quantity reduction occurs.

3.3.1.2 Less than 28-day supply

For the medications listed below in which short-term dispensing is deemed medically necessary, the program will compensate up to 1 full dispensing fee every 7 days, up to the regional maximum of the program. If these medications are dispensed daily, the program will compensate 1/7th of this fee:

  • anticonvulsants
  • antidepressants
  • antimanic agents
  • antipsychotics
  • benzodiazepines
  • contraceptives
  • estrogens
  • needles & syringes
  • nicotine replacement therapy
  • progestins
  • smoking cessation
  • stimulants

Note: These lists may be amended as required.

3.3.1.3 Implementation

When filling a new prescription for a chronic use drug, the program will pay a full dispensing fee regardless of the number of day supply. A new prescription may include a dosage change or an intermittent treatment, based on an assessment by a prescriber.

When refilling a prescription for a chronic use drug that is for less than a 28-day supply or when a need for compliance packaging is identified by the prescriber, the program will pay no more than 1 full dispensing fee per 28-day period. For the medications listed above, the program will pay no more than 1 full dispensing fee per 7-day period.

A refill is defined as the second and all subsequent fills for a given strength and dosage of a drug.

3.3.2 Opioid, benzodiazepine, gabapentin, pregabalin, stimulant and nabilone dispensing

As part of its Problematic Substance Use Strategy, the NIHB program has a 30-day maximum dispense policy for all opioids, benzodiazepines, gabapentin, pregabalin, stimulants and nabilone. The policy applies to all open benefit and limited use drugs in these classes covered under the program, as well as to those that are not listed, but are covered on a case-by-case basis.

One full dispensing fee will be paid per 30-day dispense (or less, if prescribed in a smaller quantity). Where opioids, benzodiazepines, gabapentin, pregabalin, stimulants and nabilone are prescribed to be dispensed for a longer duration as a single prescription, NIHB will reimburse up to a maximum of 30 days at a time. For claim verification purposes, prescriber approval to split a prescription into 30-day dispenses will not be required for opioids, benzodiazepines and stimulants. Please be advised that the claims processor is unable to automatically cut back the day supply to 30 days. Providers are expected to manually apply the policy.

This policy does not apply to claims submitted according to the NIHB Opioid Use Disorder Treatment Policy. For more information, please refer to section 3.5 Opioid Use Disorder Treatment.

3.3.3 Maximum quantities

Benefits that have a quantity and frequency limit do not require prior approval as long as the maximum quantity of the drug is not exceeded within a specified period of time.

Please refer to the Drug Benefit List, available on the Express Scripts Canada NIHB provider and client website, for drug specific quantity and frequency limits.

3.4 Extemporaneous mixtures

3.4.1 General

The NIHB program considers reimbursements for extemporaneous mixtures when no suitable alternative is available commercially and when prescribed in accordance with section 3.12 Prescriber policy for pharmacy benefits. Extemporaneous mixtures must not duplicate commercially available drug products. See back order exception below.

Where a corresponding pseudo-DIN for an extemporaneous mixture exists, that pseudo-DIN must be used to ensure correct reimbursement. Mixtures for which there is no pseudo-DIN but which meet open benefit requirements may be billed using the corresponding miscellaneous open benefit pseudo-DIN. Mixtures which are outside the open benefit requirements must be submitted to the Drug Exception Centre for review. If the request is approved, the limited use miscellaneous pseudo-DIN will be authorized for the claim.

The following types of extemporaneous mixtures require prior approval:

  • any extemporaneous mixture in the following extemporaneous mixture categories: internal powders, external powders, eye or ear drops, injections and suppositories, unless there is an open benefit pseudo-DIN assigned to that specific mixture
  • mixtures that contain exception or limited use ingredients and mixtures for which there are corresponding pseudo-DINs but the listing status is "limited use" or "exception"
  • extemporaneous mixtures for external use which do not comply with the eligibility criteria outlined below in section 3.4.1.1 Table 1: Reimbursement structure for extemporaneous mixtures
  • drug classes being monitored under NIHB's Prescription Problematic Substance Use Strategy, for example, stimulants, opioids, benzodiazepines, or gabapentin, unless there is an open benefit pseudo-DIN assigned to that specific mixture
  • non-standard dosage forms including, but not limited to, lozenges, lollipops, gummies, troches and slow-release products
  • mixtures containing any hormones other than corticosteroids listed on the Drug Benefit List, available on the Express Scripts Canada NIHB provider and client website
  • extemporaneous oral liquids (excluding commercially available products) containing flavourings or sweeteners may be considered on a case-by-case basis by the Drug Exception Centre for adults (please note that for children 18 years of age or younger, these are eligible without prior approval)
  • requests for payment for preparing sterile syringes where no alterations are required to the product prior to drawing up the syringe. Providers are reminded that clients should first access alternate health coverage when available, for example, through provincial home care programs. Consideration will be given to the following when determining approvals: client or caregiver ability to draw up medication into a syringe, and requirements for specialized equipment, for example, cytotoxic medications.

NIHB will reimburse according to the actual acquisition cost of covered benefits.

NIHB does not reimburse for mixing time or the cost of supplies used in the preparation or dispensing of the mixture. When the dispensing pharmacy prepares the extemporaneous mixture, the maximum dispensing fee reimbursed is in accordance with the type of product submitted as outlined below in section 3.4.1.3 Mable 1: Reimbursement structure for extemporaneous mixtures. However, if the dispensing pharmacy purchases the prepared extemporaneous mixture from another pharmacy, the dispensing pharmacy is eligible to submit up to 1 usual and customary dispensing fee*, up to the regional maximum.

3.4.1.1 Table 1: Reimbursement structure for extemporaneous mixtures
Category Eligible NIHB dispensing fee (DF) Footnote 2
Mixtures purchased from another pharmacy
All categories of mixtures Up to 1x dispensing fee
Mixtures prepared by the dispensing pharmacy
External creams, ointments, lotions, powders Up to 1.5x dispensing fee
Internal liquids, powders Up to 1.75x dispensing fee
Sterile injections, eye/ear mixtures, suppositories Up to 2x dispensing fee
3.4.1.2 Back-order items and extemporaneous mixtures

Claims for an extemporaneous mixture that is replicating a commercially available open benefit product which is on back-order do not require prior approval when the product is an external cream, ointment or lotion or an internal liquid or solid. The claim must be submitted using the corresponding pseudo-DIN where available. Otherwise, the miscellaneous pseudo-DIN for the corresponding category may be used. Providers are required to maintain documentation demonstrating that the commercially available product and interchangeable products were on back-order at the time of dispense.

3.4.2 Extemporaneous mixtures: Internal liquids

To be eligible under the NIHB program without prior approval, extemporaneous mixtures for internal liquids must:

  • only contain active ingredients indicated for internal use which are open benefits on the Drug Benefit List, available on the Express Scripts Canada NIHB provider and client website (note: ingredients from monitored drug classes such as stimulants, opioids, benzodiazepines, gabapentin, pregabalin, or nabilone require prior approval)

    OR

  • have a corresponding pseudo-DIN which is listed as an open-benefit. They must not duplicate the formulation of commercially manufactured drug products

Pharmaceutical powders of eligible ingredients may be used in lieu of tablets or capsules. These powders must be billed at actual acquisition cost and must not exceed the maximum allowable actual acquisition cost which is based on the price of the DIN of the comparable listed tablet or capsule.

3.4.3 Extemporaneous mixtures: External use

The following mixtures are eligible under NIHB without prior approval:

  • mixtures for external use with corresponding open benefit pseudo-DINs
  • mixture that are a combination of 2 or more open benefit external use products only (the use of non-medicinal bases require prior approval)
  • mixtures that are a combination of one or more external use products listed as open benefit on the Drug Benefit List, available on the Express Scripts Canada NIHB provider and client website, and one or more of the following: urea, menthol or camphor

    OR

  • mixtures that are a combination of ingredients as outlined below in section 3.4.3.1 Figure 1: Eligible ingredient combinations for external mixtures

Note: The strength of hydrocortisone in finished products must be ≥0.5%.

3.4.3.1 Figure 1: Eligible ingredient combinations for external mixtures
1 or more eligible ingredients AND 1 or more external use product listed as open benefit on the Drug Benefit List, (available on the Express Scripts Canada NIHB provider and client website) or one or more non-medicinal eligible base
Note: In situations where a generic or house brand of an eligible base exists at an equal or lower cost, this product may be used in lieu of the listed brand-name bases.
+/- 1 or more ingredients
*no minimum concentration required
  • anthralin
  • betamethasone powder
  • clindamycin powder
  • clotrimazole powder
  • coal tar/LCD
  • erythromycin powder
  • hydrocortisone powder (in strengths equal to or greater than 0.5%)
  • ketoconazole powder
  • lidocaine powder
  • metronidazole powder
  • miconazole powder
  • nifedipine powder
  • nystatin powder
  • salicylic acid powder
  • sulfur powder
  • Aquaphor
  • CeraVe cream/lotion
  • Cetaphil
  • Cliniderm
  • cocoa butter
  • cold cream
  • compound tincture of benzoin (Friar's balsam)
  • Dermabase
  • Dilusol
  • Eucerin
  • Glaxal Base
  • Ihle's Paste
  • lanolin
  • Lassar's Paste
  • Lubriderm
  • mineral oil
  • petrolatum (Vaseline)
  • cream/lotion containing a maximum of 22% urea
  • zinc oxide creams/ointments
  • Camphor*
  • Menthol*
  • Urea*

3.4.4 Extemporaneous mixtures: Topical non-steroidal anti-inflammatory (NSAID) in transdermal base

Coverage is provided for compounded topical non-steroidal anti-inflammatory as per below in section 3.4.4.1 Table 2: NIHB coverage of compounded topical non-steroidal anti-inflammatories. These products are listed as limited use, no prior approval is required up to the maximum price and quantity limits. Providers may bill up to 100 grams every 30 days. Requests for additional ingredients or to exceed the price or quantity limit can be considered on a case-by-case basis and require prior approval.

3.4.4.1 Table 2: NIHB coverage of compounded topical non-steroidal anti-inflammatories
Eligible transdermal bases Eligible topical non-steroidal anti-inflammatory powders Other eligible ingredients
Topical NSAID in transdermal base
Maximum billing quantity: 100 grams per 30 days
Price limit: actual acquisition cost up to $0.55 per gram (except Quebec)
Transdermal base
(for example, Diffusimax, PLO gel, Foamaderm, others)
Eligible NSAID powders
1 of: diclofenac or ketoprofen in a concentration of 3% - 10%
Other eligible ingredients
Menthol*
Camphor*
*no minimum concentration required
Transdermal lidocaine W/NSAID
Maximum billing quantity: 100 grams per 30 days
Price limit: actual acquisition cost up to $0.55 per gram (except Quebec)
Transdermal base
(for example, Diffusimax, PLO gel, Foamaderm, others)
Eligible NSAID powders
1 of: diclofenac or ketoprofen in a concentration of 3% - 10% Plus: lidocaine powder
Other eligible ingredients
Menthol*
Camphor*
*no minimum concentration required

3.4.5 Extemporaneous mixtures: List of ineligible ingredients and products

  • impotence drugs, for example, Caverject
  • hair growth stimulants, for example, minoxidil in topical preparations
  • homeopathic preparations
  • investigational or experimental products
  • lidocaine 5% ointment
  • natural health products unless an item is specified as a listed benefit
  • pre-made parenteral infusion bags where no alterations are required to the product prior to administration
  • products used for cosmetic purposes
  • products which recreate commercial products that are available in the same strength unless there is a shortage or back-order of these products. (See above)
  • reconstitution of a dry powder oral preparation with distilled water in accordance with its product monograph
  • reconstitution of non-sterile commercially available products such as BenzaClin
  • reimbursement for non-essential, non-medicinal ingredients (exception: flavourings and sweeteners are reimbursed for children 18 years of age or younger)
  • reimbursement for flavourings or sweeteners added to commercially available products
  • reimbursement for supplies used in the process of compounding, for example, alcohol wipes, syringes, needles and papers
  • reimbursement for supplies used to dispense final product, for example, ointment jars, bottles, syringes, atomizers, nasal spray bottles and eye droppers

For more information, please contact the NIHB Call Centre at Express Scripts Canada at toll-free 1-888-511-4666 to speak with an Express Scripts Canada representative.

3.5 Opioid use disorder treatment

3.5.1 Methadone

NIHB compensates compounded methadone (pseudo-DIN 00908835) or commercially available methadone solution, for example, Methadose, Metadol and their generics for the treatment of opioid use disorder.

The NIHB program has specific requirements for drug cost, mark-up, and dispensing fees when billing methadone for the treatment of opioid use disorder. This applies to both witnessed and carried doses. Effective October 16, 2023, the dispensing fee for methadone is based upon the following formula for each day of methadone treatment: (Dispensing Fee/7) + $5.95.

For claims filled on the same day, the electronic claim adjudication system will allow a single transaction up to a maximum 14-day supply or more than 1 transaction for a combination of up to a maximum 14-day supply. Pharmacy providers should be aware that NIHB will only pay claims from 1 provider per day and only if the total "days supply" has elapsed from a previous date of service. Claims are to be submitted reflecting the date of service provided.

When billing for compounded methadone solution for the treatment of opioid use disorder (pseudo-DIN 00908835), the quantity submitted must be in milligrams (mg) of drugs dispensed prior to any dilution. For example, if a prescriber prescribed 75 mg of methadone each day, the claim submission must indicate a quantity of 75 mg of methadone.

When billing for Methadose, Metadol or generics for the treatment of opioid use disorder, the quantity submitted must be in millilitres (mL) of drugs dispensed prior to any further dilution. For example, if a prescriber prescribed 75 mg of methadone each day, the claim submission must indicate a quantity of 7.5 mL of Methadose 10 mg/mL oral solution.

3.5.2 Buprenorphine/naloxone (Suboxone® and generics)

The NIHB program reimburses providers their usual and customary dispensing fee per dispense of oral buprenorphine/naloxone (Suboxone® and generics), up to the program's regional maximum.

Separate claim submissions are required for pharmacy-witnessed doses* and carry doses. One (1) claim is to be submitted per pharmacy-witnessed dose* and 1 claim is to be submitted for all carry doses combined, for example, regardless of the number of carry doses being dispensed at a time.

For providers who are shipping oral buprenorphine/naloxone for witnessing and distribution outside of the pharmacy, for example, to a remote community, 1 claim for all doses combined within the shipment must be submitted.

For possible dispensing scenarios, see below section 3.5.2.1 Table 3: Possible buprenorphine/naloxone dispensing scenarios. Providers are encouraged to contact the NIHB Call Centre at Express Scripts Canada at toll-free 1-888-511-4666 for questions concerning fee structures and claim submission procedures for opioid use disorder treatments.

3.5.2.1 Table 3: Possible oral buprenorphine/naloxone dispensing scenarios
Scenario Eligible NIHB dispensing fee claim submission and eligible NIHB dispensing fee
Daily dispensing for pharmacy-witnessed dosing* 1 claim (1 dispensing fee) to be submitted for each pharmacy-witnessed dose*
7 carry doses 1 claim (1 dispensing fee) to be submitted for all carry doses combined
Any combination of pharmacy-witnessed dosing* & carry doses 1 claim (1 dispensing fee) to be submitted on each day of the pharmacy-witnessed dose*
1 claim (1 dispensing fee) to be submitted for all carry doses combined
Any combination of witness doses and carry doses whereby the care/witnessing has been transferred to a:
  • physician
  • nurse
  • patient representative
  • other third party representative
  • clinic, treatment facility, nursing station, health or community centre, or other care facility
Please note: shipping oral buprenorphine/naloxone for distribution outside of the pharmacy is equivalent to the pharmacy having transferred care/witnessing.

1 claim (1 dispensing fee) to be submitted for all doses combined

For example, if a client supply of oral buprenorphine/naloxone is shipped to a health centre every 14 days for daily witnessing at the health centre, 1 claim (1 dispensing fee) is to be submitted for all doses combined regardless of whether each dose is shipped with its own prescription number or not.

*A pharmacy-witnessed dose is a dose that is directly witnessed by a pharmacy employee. This may occur either within the pharmacy premises or, where permitted by jurisdictional regulations, off-site by a pharmacy employee.

3.5.3 Kadian®

The NIHB program will consider covering Kadian® for the treatment of opioid use disorder where methadone and buprenorphine/naloxone (Suboxone® and generics) are not available or not appropriate. If client is receiving 1 witnessed dose plus carries, providers may submit 1 claim for the witnessed dose and 1 claim for the carries. For example, if a client is receiving 1 witnessed dose with 3 carries, this could be billed as 2 claims.

For providers who are shipping Kadian® for witnessing and distribution outside of the pharmacy, for example, to remote communities, a single claim per dispense should be submitted.

3.5.3.1 Table 4: How Kadian® is to be billed when used to treat opioid use disorder
Medication pseudo-DIN
Kadian® 10 mg 09991310
Kadian® 20 mg 09991311
Kadian® 50 mg 09991312
Kadian® 100 mg 09991313

The program will reimburse providers their full usual and customary dispensing fee, up to the program's regional maximum, per dispense.

3.5.4 Buprenorphine extended-release injection (Sublocade®)

NIHB reimburses providers their usual and customary dispensing fee for buprenorphine extended-release injection (Sublocade®), up to the program's regional maximum.

NIHB will also reimburse pharmacy providers for administration of Sublocade® by injection. Providers may submit for reimbursement using pseudo-DIN 96100008 if it is administered by either an employee of the pharmacy provider, or by a health professional contracted by the provider to administer injections and the Sublocade® has been reimbursed by NIHB.

3.5.5 Buprenorphine subdermal implant (Probuphine®)

NIHB lists buprenorphine subdermal implant (Probuphine®) as a limited use benefit. Please refer to the Drug Benefit List, available on the Express Scripts Canada NIHB provider and client website, for limited use criteria.

3.6 Emergency supply process

Quick links

The NIHB program has a provision allowing providers to dispense medications requiring prior approval on an emergency basis.

When an eligible drug requiring prior approval is needed by an NIHB client on an emergency basis and the criteria for automated prior approval have not been met, for example, a claim is submitted on-line and a prior approval is not electronically granted as indicated by the generated Canadian Pharmacist Association (CPhA) message, a provider may dispense an initial emergency course of treatment of up to a 14-day supply. This only applies if access to the Drug Exception Centre is not possible, for example, due to unforeseen system issues, on statutory holidays, and after hours of operation. In such situations, an emergency dispense may be provided without prior approval. The provider must then resubmit the request for authorization through the prior approval process as soon as the Drug Exception Centre is available during regular business hours so that it can be reviewed for emergency supply coverage right away.

After an emergency dispense, providers must follow the usual prior approval process to dispense the balance of the prescription. If authorization is granted for the remainder of the prescription, the:

  • Pharmacist will receive a prior approval or special authorization confirmation with details of the approved benefit by mail or fax (provider preference).
  • Prior approval number must then be included on the subsequent submitted claim. Claim submissions for drugs dispensed as an emergency supply during regular hours of operation of the Drug Exception Centre are subject to recovery.

3.7 Refusal to fill (dispense) fee

A pharmacy provider in British Columbia, Saskatchewan, or Manitoba may decide not to dispense a prescription when a claim has been returned through the Drug Utilization Review and it is deemed to be in the best interest of the client. In these cases, a fee equal to the provider's usual and customary fee may be charged to the NIHB program through the refusal to fill (dispense) fee. The provider is advised to resubmit the original claim and use the 'UL' intervention code, along with the original information on their claim. Please refer to the Pharmacy Claims Submission Kit available on the Express Scripts Canada NIHB provider and client website for more information.

3.8 Trial Rx Program

Quick links

A Trial Rx Program is intended to help determine if a client can tolerate a specific drug without experiencing side effects. This program is only applicable to EDI claims for British Columbia and Saskatchewan with or without a verified prior approval number. Under the Trial Rx Program, clients receive a 7-day supply of a new medication to determine if it is tolerated. Please refer to the Pharmacy Claims Submission Kit, available on the Express Scripts Canada NIHB provider and client website, for details on adjudicating Trial Rx Program claims.

3.9 Manual claims submission

Providers who do not have access to the Internet may contact the NIHB Call Centre at Express Scripts Canada at toll-free 1-888-511-4666 to request a copy of the forms required to submit a manual claim for items which require a prior approval or special authorization. Please refer to the Pharmacy Claims Submission Kit, available on the Express Scripts Canada NIHB provider and client website, for detailed information on how to submit manual claims, including forms required and necessary information.

Drugs with potential problematic use require close monitoring by health care providers, such as prescribers and pharmacists, to maximize safety and effectiveness and minimize the risk of harm and diversion. In order for the program to provide coverage for these medications appropriately, information about drug claims must be received in an accurate and timely manner. The adjudication system for the NIHB program, Health Information and Claims Processing Services (HICPS) ensures this by adjudicating claims in real time. In order to ensure client safety and program integrity, all claims for methadone, buprenorphine/naloxone (Suboxone® and generics), opioids, benzodiazepines or stimulants must be adjudicated at the point of sale. Provider manual claims and client reimbursement will not be permitted for these drugs.

3.10 Reversals for prescribed medication not picked up by client

When a client has not picked up a prescription within 30 days, the original paid claim must be reversed and resubmitted for payment of only the dispensing fee.

The submission of a claim for a dispensing fee where the client has not picked up a drug, which can be reinserted to inventory, only applies to drugs with a dispensing fee dollar value.

Where the drug item is an eligible compound and reinsertion into the pharmacy's inventory is not possible, Express Scripts Canada pays the provider for both the drug and dispensing fee. Therefore, a reversal is not necessary. The Drug Utilization Review Program is not affected.

Please refer to the Pharmacy Claims Submission Kit, available on the Express Scripts Canada NIHB provider and client website, for details on adjudicating reversals.

3.11 Balance billing

When submitting claims, providers are required to submit the usual and customary dispensing fee to the NIHB program according to their NIHB Pharmacy Billing Agreement. Providers are also required to update the usual and customary dispensing fees in their system based on the agreed upon dispensing fees.

The maximum dispensing fees accepted by the program are negotiated by the NIHB program. Any usual and customary dispensing fee exceeding the allowable maximum is not to be charged to NIHB clients.

3.12 Prescriber policy for pharmacy benefits

To be eligible for reimbursement, all prescribers must meet the following conditions:

  • the prescribers must be licensed by and in good standing with the respective governing body or province in which they practice
  • the prescription has been written in accordance with federal and provincial legislation
  • the prescription falls within the health professional's scope of practice, as defined by the relevant provincial and territorial regulations

In addition, the NIHB program accepts client-specific written recommendations for the National Association of Pharmacy Regulatory Authorities (NAPRA) Schedule IIIII, unscheduled (non-prescription) drugs and other eligible health products when the item(s) falls within the health care provider's scope of practice.

The NIHB program requires providers to maintain documentation related to claims submitted as a result of a health professional's recommendation. At a minimum this must include the following information:

  • date
  • name and date of birth of the client
  • proper name, common name, or brand name of the recommended drug, and the quantity thereof
  • dosage
  • signature of the health professional

Claims submitted according to this policy will be reimbursed for the drug cost and dispensing fee according to NIHB reimbursement policies. All claims are subject to claims verification.

3.13 Health Canada's Special Access Program (SAP)

Quick links

NIHB will consider, on a case-by-case basis, claims for drugs available through Health Canada's Special Access Program (SAP). Drugs considered for release by the Special Access Program include pharmaceutical, biologic, and radio-pharmaceutical products not approved for sale in Canada. Drugs used for psychedelic-assisted therapies approved through Health Canada's Special Access Program will not be considered for coverage as they are exclusions to the NIHB program.

Providers should follow the usual process for prior approval of pharmacy benefits and contact the Drug Exception Centre to submit requests. The Drug Exception Centre will validate requested costs using manufacturer receipts or invoices; adjustments may be needed based on the exchange rate. Where the drug has been supplied to pharmacies at no cost, NIHB will consider requests for reimbursement of the dispensing fee alone. Where the Special Access Program drug is compounded into an extemporaneous mixture, it will be billed using the Special Access Program pseudo-DIN and the dispensing fee will be adjusted according to the extemporaneous mixture reimbursement policy.

Clients who have paid for medications received through the Special Access Program may submit requests for reimbursement to NIHB using the Client Reimbursement Form, available on the Express Scripts Canada NIHB provider and client website; these requests will be reviewed by the Drug Exception Centre for approval prior to reimbursement. Where the client reimbursement process is followed, NIHB will consider reimbursing based on the manufacturer receipt, at the current exchange rate, and documentation of dispensing of the medication by the physician, in lieu of an official pharmacy receipt, where applicable.

4.0 Payment and reimbursement

Upon signing the Pharmacy Billing Agreement with NIHB's claim processor, providers are advised to read and retain an up-to-date Pharmacy Claims Submission Kit available on the Express Scripts Canada NIHB provider and client website. The kit outlines all the accountability rules and obligations for providers to ensure that they have the information they need to submit claims for payment.

4.1 Coordination of benefits

Persons eligible for benefits under the NIHB program are required to access other public or private health plans or provincial or territorial programs for which they are eligible before accessing NIHB benefits. Pharmacy providers must confirm with each client whether other coverage exists because a claim must be submitted to the other party first for processing. Once this party processes the claim, the provider may then submit to NIHB for payment.

4.1.1 Coordination with Ontario Drug Benefit (ODB) program

Some NIHB clients living in Ontario may be eligible for drug coverage under the Ontario Drug Benefit (ODB) program.

NIHB clients who are age 24 or under and also eligible for OHIP+ may access drug coverage from either NIHB or, if they are eligible, through the OHIP+ program. Claims cannot be coordinated.

NIHB will pay the copayments for Ontario Drug Benefit coordinated claims; however, once the maximum number of dispensing fees has been paid by Ontario Drug Benefit, NIHB will not pay additional dispensing fees for a coordinated claim. If an Ontario Drug Benefit recipient meets the Ontario Drug Benefit's established exemption criteria, then NIHB will continue to reimburse the copayment or deductible as applicable. Any Ontario Drug Benefit ineligible dispensing fee should not be charged to NIHB, for example, when Ontario Drug Benefit pays for the drug cost but not the dispensing fee, NIHB should not be charged a fee.

4.1.2 Termination of alternative coverage

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When an eligible client indicates that they no longer have benefit coverage through another private or public health care plan or social program, the provider or the client is asked to communicate this to the NIHB program so that the client's file can be updated.

5.0 Appendices

5.1 Client eligibility

The provider must verify that the individual is eligible for benefits under Indigenous Services Canada's NIHB program and identify any other benefit coverage available to the client, if applicable.

To be eligible, a client must be a resident of Canada, and one of the following:

  • a First Nations individual who is registered according to the Indian Act (commonly referred to as a "Status Indian")
  • an Inuk recognized by one of the Inuit land claim organizations as outlined in Inuit client eligibility for NIHB
  • a child less than 2 years old, whose parent is an NIHB-eligible client

Refer to the Who is eligible for the NIHB program webpage or contact the NIHB regional office for information.

More detailed information about client identification and eligibility can be found in section 4 of the Pharmacy Claims Submission Kit, available on the Express Scripts Canada NIHB provider and client website.

5.2 Privacy statement

Indigenous Services Canada's NIHB program has a responsibility to protect personal information under its control in accordance with the Privacy Act and its related Treasury Board privacy policy and directives and is responsible for ensuring the personal information collected is limited to that which is necessary to administer the program.

For more information, please contact Indigenous Services Canada's Access to Information and Privacy (ATIP) Coordinator at 819-997-8277 or aadnc.atiprequest-airprpdemande.aandc@canada. You also have the right to file a complaint with the Privacy Commissioner of Canada if you think your personal information has been handled improperly.

5.3 Appeal process

Quick links

Persons eligible for the NIHB program have the right to appeal the denial of a benefit with the exception of items that are identified as exclusions or insured services. If a client seeks information about the appeal process, pharmacy providers may direct them to the online appeal procedures, or to the appropriate First Nations and Inuit Health Branch regional office.

5.4 Provider Claim Verification Program

Quick links

As part of the NIHB program's risk management activities, Indigenous Services Canada has mandated its claims processor to maintain a set of pre-payment and post-payment processes, including claim verification activities.

This function incorporates the review of claims against records to confirm compliance with the terms and conditions of the NIHB program. If under any circumstances it is found that a provider has inappropriately billed the program, claim payments will be recovered; either by direct payment from the provider or withheld from future provider claim statements.

Detailed information about the Provider Claims Verification Program and procedures can be found in section 6 of the Pharmacy Claims Submission Kit available on the Express Scripts Canada NIHB provider and client website.

6.0 Frequently asked questions

6.1 Short-term dispensing questions and answers for providers

Q1. What is the NIHB short-term dispensing policy?

The NIHB short-term dispensing policy establishes compensation criteria for dispenses of certain chronic use medications where short-term dispensing is medically necessary. The short-term dispensing policy consists of two reimbursement models, depending upon the type of medication being dispensed.

Q2. What is the purpose of the NIHB short-term dispensing policy?

This short-term dispensing policy is not intended to interfere with or question treatment approaches or judgements made by pharmacists or prescribers on how clients receive their medications. Rather, it sets out guidelines on how NIHB will compensate pharmacists for dispensing certain medications. Certain medications required for long-term maintenance therapy should be dispensed in up to 100 days supplies. For refills for medications requiring a shorter term dispensing less than 28 days due to compliance concerns, the short-term dispensing policy applies.

Q3. How many NIHB short-term dispensing policies are there?

NIHB has one short-term dispensing policy depending on the type of two reimbursement models:

  • the 7-day short-term dispensing reimbursement model: maximum of one full dispensing fee every 7 days
  • the 28-day short-term dispensing reimbursement model: maximum of one full dispensing fee every 28 days
Q4. What is the list of medications under the 7-day short-term dispensing reimbursement model?
  • anticonvulsants
  • antidepressants
  • antimanic agents
  • antipsychotics
  • benzodiazepines
  • contraceptives
  • estrogens
  • needles & syringes
  • nicotine replacement therapy
  • progestins
  • smoking cessation
  • stimulants
Q5. What is the list of medications under the 28-day short-term dispensing reimbursement model?
  • alpha-adrenoreceptor antagonists
  • anticoagulants
  • anti-dementia drugs
  • antiemetics for cancer chemotherapy
  • anti-gout drugs
  • antihistamines
  • anti-platelet
  • anti-parkinsonian drugs
  • benign prostatic hyperplasia (BPH) drugs
  • cardiovascular drugs
  • drugs for diabetes
  • drugs for treatment of bone diseases
  • enzyme preparations
  • gastrointestinal (GI) anti-inflammatory drugs
  • H2-receptor antagonists
  • immunosuppressants
  • non-steroidal anti-inflammatory drugs (NSAIDs)
  • over-the-counter (OTC) products (including vitamins)
  • other drugs for peptic ulcer and gastro-esophageal reflux disease (GERD)
  • prokinetic agents
  • proton pump inhibitors
  • respiratory smooth muscle relaxants
  • synthetic antidiuretic hormone
  • thyroid therapy
  • urinary anti-spasmotics
Q6. What are the exceptions to the 2 short-term dispensing reimbursement models?

The short-term dispensing policy does not apply to medications under these circumstances:

  • refills for intermittent treatment of a chronic disorder or refills of a medication which are prescribed to be taken on an "as needed" (PRN) basis. Note: Medications prescribed to be taken on an "as needed" (PRN) basis and dispensed chronically may be subject to audit and recovery
  • prescriptions for dose changes
  • injectable and suppository dosage forms
  • refills or new prescriptions when prescribed/dispensed in accordance with a court order
Q7. If the prescriber writes a prescription for 'daily dispense', is this sufficient documentation to allow for a full dispensing fee?

No. A prescription with the direction of 'dispense daily' or 'daily dispense' is not a sufficient rationale for the program to reimburse differently than as described in the NIHB short-term dispensing policy. The dispensing frequency is at the discretion of the prescriber and pharmacist. However, compensation under the NIHB program is based on program policies.

Q8. What happens if the pharmacy dispenses the classes of medications listed above more frequently than once every 7 or 28 days depending of the medication class?

The dispensing fee should be submitted according to the following formula:

[(usual and customary dispensing fee (up to NIHB maximum) /7 or 28 days) x days supply]. The dispensing frequency is at the discretion of the prescriber and pharmacist; however, compensation to the pharmacist under the NIHB program is based on program policies.

Q9. Does the policy change affect the benefit status of medications?

No. Benefit status of medications is independent of the short-term dispensing policy.

Q10. How can claims that have already been sent be adjusted?

Providers have up to 30 days from the date of service to reverse and resend claims submitted incorrectly. The provider can reverse the original claim and resubmit.

Q11. If the pharmacy is billing every day, can the pharmacy bill the full dispensing fee on the first of the 7 days (with an override code) and bill the remaining 6 days without a dispensing fee?

No. The provider should calculate the adjusted fee as above and submit daily. It is the NIHB program's policy that claims are submitted appropriately on the date of service and not in advance. Claims submitted otherwise are subject to audit and recovery.

Q12. Does the short-term dispensing policy replace NIHB's 100-day supply policy?

No. With the implementation of the changes to the short-term dispensing policy, it is the program's expectation that most chronic use medications will continue to be prescribed in 100-day supplies and dispensed in 100-day intervals.

Q13. What is a "full dispensing fee"?

A "full dispensing fee" is the pharmacist's usual and customary dispensing fee, up to the regional maximum of the program.

Q14. What if it is a medication that the client has already received, but the client is new to the pharmacy?

The claim would be considered a "new prescription", since the pharmacist has not seen the client before. It is understood that additional work may be required by the pharmacist when a client is seen for the first time.

Q15. How does short-term dispensing policy affect other medications on the Drug Benefit List?

There is no effect on other medications included in the Drug Benefit List. Other medications, with the exception of extemporaneous mixtures, not under the short-term dispensing policy are covered as per the day supply on the prescription and claims include a full dispensing fee.

Q16. Will the list of drugs that are subject to the short-term dispensing policy change over time?

Yes, the list of medications can be expected to change over time. Any changes will be communicated via updates to the NIHB Drug Benefit List as well as in the quarterly NIHB provider newsletters.

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