Non-Insured Health Benefits program updates

New pharmacy benefit listings

Refer to the Drug Benefit List to find all eligible products and criteria for coverage.

The following medications and products are now covered as open benefits without prior approval:

• Vemlidy (tenofovir alafenamide) for the treatment of chronic hepatitis B in adults

The following listings are covered as limited use benefits with prior approval:

• Praluent (alirocumab) pre-filled pens previously listed at 75mg/ml and 150mg/ml, now available in 300mg/2ml pre-filled pens, for the treatment of adult patients with high cholesterol
• Venclexta (venetoclax) for the treatment of chronic lymphocytic leukemia (CLL)
• Omlyclo (omalizumab) for the treatment of severe asthma caused by an allergy
• Fruzaqla (fruquintinib) for the treatment of metastatic colorectal cancer
• Evkeeza (evinacumab) for the treatment of adult and pediatric patients aged 5 years and older with very high cholesterol
• Bylvay (odevixibat) for the treatment of severe itching in patients with progressive familial intrahepatic cholestasis, a condition affecting the liver
• Ultomiris (ravulizumab) for the treatment of certain conditions affecting the nerves

Addition of Humira and Humira Citrate free to the biosimilar transition policy

• Under the NIHB Biosimilar Transition Policy, clients 19 years of age and older who are taking certain medications are required to transition to the biosimilar version of their medication in order to maintain coverage
• This policy aligns with other provincial and territorial drug plans and helps support consistent client access to medications and care
• Adalimumab (Humira and Humira Citrate free) is now included under this policy, in addition to Enbrel, Remicade and Rituxan
• Clients who are currently taking Humira and Humira Citrate free have until May 25, 2026 to transition to a biosimilar version of their medication in order to maintain coverage
• Make an appointment to speak with your health care provider if this change applies to you. Pharmacists and prescribers are well informed about biosimilars and have already helped many people transition to these medications
• Consult the Health Canada website for more information on biosimilar biologic drugs

New coverage for enteral EnFit feeding syringes

• NIHB now provides coverage for two new Enfit feeding syringe sizes: 3 cc/mL, and 20 cc/mL
• More information can be found in section 9.0 Self-care of the NIHB Medical Supplies and Equipment Guide and Benefit lists

Addition of mental health counsellors as recommenders of gender Identity Items

• NIHB now accepts mental health counsellors recognized by the program as eligible medical supplies and equipment recommenders for gender identity items, where allowed under their provincial and territorial scope of practice
• For more information on provider eligibility in your province or territory, please refer to section 9.0 Self-care of the NIHB Medical Supplies and Equipment Guide and Benefit Lists

Reminder: client web accounts

• NIHB clients have the option of creating a secure, online personal account through the Express Scripts Canada NIHB Provider and Client Website
• Express Scripts Canada processes claims for NIHB pharmacy, medical supplies and equipment, dental, vision care and mental health counselling benefits
• Your secure web account can be used to view claims and submit client reimbursement requests, and submit appeals
• To create an online web account, please visit Client Benefits on the Express Scripts Canada website and click 'Create Web Account'
• Account registration and password resets cannot be done on a mobile device. You must use a computer with a web browser (Internet Explorer, Microsoft Edge, Google Chrome, Safari or Mozilla Firefox)
• Your name, date of birth, and status or N number must match exactly as it appears on your First Nation status card or Inuit land claim beneficiary card to avoid issues with account creation
• If you have problems with your client account or need to reset your password, please contact NIHB Call Centre at Express Scripts Canada at 1-888-441-4777 for assistance

New pharmacy benefit listings

Refer to the Drug Benefit List to find all eligible products and criteria for coverage

The following medications and products are now covered as open benefits without prior approval:

• Orgovyx (relugolix) for the treatment of prostate cancer
• Axberi (enoxaparin sodium), a blood thinner, for the prevention or treatment of conditions such as deep vein thrombosis (DVT), unstable angina or heart attack
• Cabtreo Gel (clindamycin phosphate/adapalene/benzoyl peroxide gel) for the topical treatment of acne vulgaris
• Nextsellis (estetrol monohydrate and drospirenone) for the prevention of pregnancy
• Fulphila and Niopeg (pegfilgrastim) to reduce the chance of infection for persons receiving some chemotherapy treatments

The following listings are covered as limited use benefits with prior approval:

• Brukinsa (zanubrutinib) for the treatment of chronic lymphocytic leukemia (CLL)
• Wezlana (ustekinumab) pre-filled pens for the treatment of plaque psoriasis, psoriatic arthritis, Crohn's disease, and ulcerative colitis
• Epidiolex (cannabidiol) for the treatment of certain seizure conditions
• Tyenne (tocilizumab) for treatment of rheumatoid arthritis, arthritis in children 2 years of age and older, and giant cell arteritis in adults, a condition that causes inflammation of the arteries
• Wainua (eplontersen) for the treatment of polyneuropathy, a condition affecting the nerves
• Xcopri (cenobamate) for the treatment of partial-onset seizures in adults
• Velsipity (etrasimod) for the treatment of ulcerative colitis
• Tibsovo (ivosidenib) for the treatment of patients with newly diagnosed acute myeloid leukemia (AML)
• Uplizna (inebilizumab) for the treatment of adult patients with neuromyelitits optica spectrum disorder (NMOSD), an autoimmune disease affecting the central nervous system
• Myalepta (metreleptin) for the treatment of leptin deficiency in patients with lipodystrophy
• Livmarli (maralixibat) for the treatment of severe itching in patients with Alagille syndrome, a condition affecting the liver and other organs

Coverage of continuous glucose monitoring system: FreeStyle Libre 3

• NIHB has added the FreeStyle Libre 3 continuous glucose monitoring (CGM) system reader and sensors, as a limited use benefit for clients managing diabetes with insulin. Prior approval is required
• Coverage includes 1 reader every 3 years, and 14 sensors every 6 months. Criteria are listed in the Drug Benefit List
• In addition to FreeStyle Libre 3, NIHB continues to cover other CGM systems, including:
  • FreeStyle Libre 2
  • Dexcom G6 and Dexcom G7
  • Guardian Connect
• NIHB continues to provide coverage of diabetes test strips. Clients managing diabetes with insulin are eligible for up to 800 test strips per 100 days

New coverage for enteral feeding supplies

• NIHB now provides coverage for four new enteral feeding syringe sizes: 6cc/mL, 12cc/mL, 35cc/mL and 60cc/mL
• More information can be found in section 9.0 Self-care of the NIHB Medical Supplies and Equipment Guide and Benefit Lists

New installation coverage policy for select self-care items

• NIHB now covers installation costs for select self-care medical equipment
• Coverage is based on an hourly rate and the estimated time required for installation. Prior approval is required
• Coverage is eligible only when certain conditions are met
• For more details, see section 9.0 Self-care of the NIHB Medical Supplies and Equipment Guide and Benefit Lists

Coverage for bariatric safety pole

• NIHB now provides coverage for bariatric floor-to-ceiling poles as an open benefit at a recommended replacement frequency of 1 every 10 years
• For more details, see section 9.0 Self-care of the NIHB Medical Supplies and Equipment Guide and Benefit Lists

Reminder: NIHB client eligibility and registration

• To be eligible for coverage under the NIHB program, a client must be a resident of Canada, and 1 of the following:
  • a First Nations individual who is registered under the Indian Act, commonly referred to as a person with Indian status
  • an Inuk recognized by an Inuit land claim organization as outlined in Inuit client eligibility for the NIHB program
  • a child less than 2 years old whose parent is an NIHB-eligible client
• Parents or guardians should begin the application process for their child's First Nation status or recognition by an Inuit land claim organization as early as possible and well before the child's second birthday to ensure uninterrupted coverage
  • for information on First Nations registration, visit How to apply for Indian status
  • for information on Inuit beneficiary enrollment, contact your land claim organization
• NIHB-eligible First Nations and Inuit require a client identification number in order to access NIHB benefits
• If you are First Nations, your status registration number, located on your Indian Status Card, is used as your NIHB client identification number
  • If you need to renew or replace your status card, visit Get, renew or replace a status card. If your card has expired, you are still eligible for NIHB services while you renew your card
• If you are an Inuit client, you can use either your Northwest Territories health card number, Nunavut health card number, or your NIHB Client Identification Number (N number)
  • Learn how to get your N number from the NIHB program
• If your identification document does not include a photo, you will also need a piece of government issued photo ID (health card, drivers license, etc.) when accessing services

New pharmacy benefit listings

Refer to the Drug Benefit List to find all eligible products and criteria for coverage

The following medications and products are now covered as open benefits without prior approval:

• Apretude (cabotegravir) a long-acting injectable pre-exposure prophylaxis (PrEP) to reduce the risk of HIV

The following listings are covered as limited use benefits with prior approval:

• Remsima (infliximab) for the treatment of Crohn's disease, ulcerative colitis, and rheumatoid arthritis in adult patients
• Sohonos (palovarotene) to reduce the formation of heterotopic ossification (HO) in persons with fibrodysplasia ossificans progressive (FOP), a rare connective tissue disease
• Vyvgart (efgartigimod alfa) for the treatment of adult patients with generalized myasthenia gravis, an autoimmune disease affecting the nerves and muscles
• Orladeyo (Berotralstat) for the treatment of patients aged 12 years and older with hereditary angioedema (HAE), a condition causing severe swelling in the body
• Imbruvica (ibrutinib) for the treatment of some types of cancers
• Ixifi (infliximab) for the treatment of rheumatoid arthritis, psoriatic arthritis, ankylosing spondylitis, psoriasis, Crohn's disease and ulcerative colitis
• Truqap (capivasertib) for the treatment of breast cancer

Coverage status change for Ozempic

• Effective July 14, 2025, the listing status of Ozempic has changed to limited use. New coverage requests require prior approval
• This change will not affect clients who are already receiving coverage of Ozempic through NIHB
• Ozempic continues to be covered for the treatment of type 2 diabetes in adults, in combination with metformin or similar medications
• In most cases coverage of Ozempic will be approved automatically when the claim is submitted, if the client meets criteria
• If a coverage request for Ozempic is not approved automatically, pharmacy providers can submit a prior approval request to the NIHB Drug Exception Centre for consideration

Certain eczema medications now covered as open benefits

• NIHB now lists Protopic ointment and Elidel cream as open benefits. Prior approval is not required
• Previously, NIHB only covered these medications if clients did not respond to other eczema treatments, following Health Canada's earlier recommendations

Reminder: Coverage of Pre-exposure prophylaxis (PrEP) to prevent HIV infection

• NIHB provides coverage for PrEP treatments, which help to prevent HIV in individuals who are at high risk of infection
• Tenofovir disoproxil fumarate-emtricitabine (Truvada and generics) and Apretude (cabotegravir) are covered as open benefits. Prior approval is not required
• Talk to your healthcare provider about whether PrEP is right for you. To learn more, see the Public Health Agency of Canada publication on biomedical prevention of HIV

New coverage for prosthetic supplies

• NIHB will now provide coverage for the replacement skin finish for a prosthetic device
• More information can be found in section 7.0 Prosthetics of the NIHB Medical Supplies and Equipment Guide and Benefit Lists

New eligible prescribers of low vision items and services

• NIHB now recognizes optometrists and ophthalmologists as eligible prescribers of assistive technology aids for low vision, low vision functional assessments and low vision training programs
• For more information, please refer to section 10.0 Low vision of the NIHB Medical Supplies and Equipment Guide and Benefit Lists

Understanding frequency of coverage for general eye exams, corrective eyewear and repairs

• Frequency of coverage for general eye exams, as well as corrective eyewear and repairs, is based on age and follows a calendar year from January 1 to December 31

• To confirm your eligibility for vision care benefits, you can use the eligibility function on your NIHB web account or contact the NIHB Call Centre at Express Scripts Canada at 1 888 511-4666
• Clients must first access all provincial, territorial, or private health insurance plans or programs for which they are eligible, before accessing coverage through NIHB
• For more details about coverage and frequency, see section 2.2 Eye examination frequency guidelines, section 3.2 Corrective eyewear frequency guidelines and section 3.4.7 Exception: Repairs or replacement due to breakage, damage or loss in the NIHB Vision Care Benefits Guide

Reminder: submitting dental appeal documents

• If you are denied NIHB coverage of a dental or orthodontic service, the decision can be appealed by the client, a parent or legal guardian, or a client representative. Clients can submit appeal requests online or by mail:
  • Online submission: clients will need to create a secure web account on the Express Scripts Canada NIHB provider and client website
  • Mail submissions: label your envelope "Appeal - Confidential" and mail it to the NIHB Dental Predetermination Centre, using the address for either dental or orthodontic services
• If you are submitting an appeal through your online web account, upload only documentation pertaining directly to your appeal. Any other information submitted through the appeal web page, such as client reimbursement claims, will not be processed.
• All appeals require an appeal letter that is signed and dated by the client, client representative or legal guardian, along with current supporting documentation of good diagnostic quality (radiographs, a treatment plan, or clinical findings, etc.). If the appeal letter is not signed and clearly marked as an appeal the request will be treated as a standard predetermination and may result in the appeal being returned unprocessed
• Services identified as exclusions under the NIHB Program will not be considered for appeal. For details on dental benefit exclusions, please see Appendix F: Exclusions of the NIHB Dental Benefits Guide
• If you have questions or would like support with the dental appeal process, you can contact the NIHB Dental Predetermination Centre or an NIHB Navigator in your region

Express Scripts Canada video tutorials on client web accounts

• Express Scripts Canada processes NIHB claims for pharmacy, dental, vision care, medical supplies and equipment, and mental health counselling benefits
• NIHB clients can create a secure web account to view claims, submit client reimbursement requests, and submit appeals
• New instructional videos are available on the Express Scripts Canada website to help clients understand and use the features of their NIHB web account
• To view the videos, go to the Express Scripts Canada client website and click on the thumbnail titled 'Features for Clients.'

Reminder: provider billing

• Many health benefit providers are enrolled with NIHB to bill the program directly for eligible benefits provided to NIHB clients
• NIHB recommends that before you receive any item or service, you should speak to your provider's office to confirm if:
  • the provider is enrolled with NIHB and will bill the program directly
  • the item or service is fully covered by NIHB
  • the provider will not charge you any additional fees
• Clients will need to know their NIHB client identification number, and share this with the provider's office so their provider can bill the program for the items or services provided
• If your provider does not bill NIHB directly, you can contact the NIHB program for assistance to find an alternate provider
• Clients who pay for eligible services up front can submit their claims to NIHB for reimbursement. Find complete instructions on the Client reimbursement page of the Express Scripts Canada NIHB website

New pharmacy benefit listings

Refer to the Drug Benefit List to find all eligible products and criteria for coverage

The following medications and products are now covered as open benefits without prior approval:

• Mezera 1G Tab (mesalazine) for treatment of mild to moderate ulcerative colitis
• Naloxone Prefilled Syringes 0.4mg/ml for emergency use to reverse known or suspected opioid overdose
• Teva-Naloxone (naloxone hydrochloride) 4mg nasal spray for emergency use to reverse known or suspected opioid overdose
• Slynd (drospirenone), an oral birth control pill

The following listings are covered as limited use benefits with prior approval:

• Akeega (niraparib and abiraterone acetate) for the treatment of prostate cancer
• Amvuttra (vutrisiran) for the treatment of polyneuropathy, a condition affecting the nerves
• Eylea HD (aflibercept) for the treatment of some macular degeneration and diabetic eye disease
• Koselugo (selumetinib) for the treatment of patients aged 2 to 18 years of age with neurofibromatosis type 1, a genetic condition that causes tumours on nerve tissue
• Omvoh (mirikizumab) for the treatment of moderate to severe ulcerative colitis
• Qulipta (atogepant) for the treatment of chronic migraines
• Steqeyma (ustekinumab) for the treatment of plaque psoriasis, psoriatic arthritis, and Crohn's disease
• Trikafta (elexacaftor-tezacaftor-ivacaftor) for the treatment of cystic fibrosis in patients aged 2 years and older
• Welireg (belzutifan) for the treatment of adult patients diagnosed with von Hippel-Lindau (VHL) disease, a type of kidney cancer

Change in coverage for some biologic medications

• The NIHB Program is changing coverage for certain biologic drugs.  This change has already been introduced in Alberta and Atlantic regions and will now apply to all provinces and territories
• Under the NIHB Biosimilar Policy, clients 19 years of age and older will be required to transition to the biosimilar version of their medication in order to maintain coverage
• Clients will have approximately 1 year to transition to the biosimilar version of their medication.  As such, clients in Alberta and Atlantic should transition to the biosimilar medication by November 25, 2025, and clients in all other regions should transition by March 4, 2026
• Most provincial and territorial drug plans have already implemented similar policies for coverage of biosimilar medications.  Aligning NIHB coverage with other public drug plans supports consistent client access to medications and care
• This change applies to 3 biologic medications, listed below along with the biosimilar versions:
  • Enbrel® (etanercept) – transition to Brenzys® , Erelzi®, or Rymti®
  • Remicade® (infliximab) – transition to Inflectra®, Renflexis™, or Avsola™
  • Rituxan® (rituximab) – transition to Ruxience®, Truxima®, or Riximyo®
• Make an appointment to speak with your health care provider if this change applies to you.  Pharmacists and prescribers are well informed about biosimilars and will help you transition to a biosimilar medication that's right for you
• Consult the Health Canada website for more information on biosimilar biologic drugs

Reminder of Shingrix coverage

• Shingrix is a vaccine to prevent shingles, which causes a painful rash and can be severe for some people. The risk of shingles is higher in seniors and in people with weaker immune systems
• NIHB covers Shingrix as an open benefit for clients 60 years and older
• Shingrix is listed on the Adjunct Cancer Formulary so coverage is available for clients undergoing cancer treatments
• NIHB also considers coverage for immunocompromised clients under 60 years of age on an exceptional basis (prior approval required)
• In most provinces and territories, the Shingrix vaccine can often be administered in pharmacies and pharmacists can bill NIHB for an injection fee
• If you are unable to have the vaccine administered at a pharmacy, ask your health care provider about other options

New replacement guidelines for feeding supplies

• NIHB will now cover extension sets for enteral feeding with a recommended replacement guideline of 24 per year. Prior approval is not required within Program replacement guidelines
• For more information, refer to section 9.5.3 Enteral feeding of the Self-care equipment and supplies benefits list

Registered dietitians as recommenders of breastfeeding aids

• NIHB now accepts recommendations from Registered Dietitians for coverage of manual breast pumps, electric breast pumps and nipple shields
• For more information on eligible items, please refer to section 9.5 Feeding of the Self-care equipment and supplies benefits list

New coverage for single-use negative pressure wound therapy supplies

• NIHB now covers single-use negative pressure wound therapy devices for up to 8 weeks for clients with chronic wounds that are not responding to conventional treatments. Prior approval is required
• Traditional or hospital grade negative pressure wound therapy devices and their related supplies are not eligible for coverage
• For more information, refer to section 13.4 Wound care of the Medical surgical equipment and supplies benefits lists

New pharmacy benefit listings

Refer to the Drug Benefit List to find all eligible products and criteria for coverage

The following listings are covered as limited use benefits with prior approval:

• Jamteki (ustekinumab) for the treatment of plaque psoriasis and psoriatic arthritis
• Guardian Link 4 Transmitter Kits for the 780G insulin pump system and Guardian Sensor 4 are covered for clients 19 years or younger on intensive insulin with type 1 diabetes
• Cabometyx (cabozantinib) for the treatment of certain types of cancer when combined with other treatments

Coverage status change for Paxlovid

• Paxlovid is now covered as an open benefit, no prior approval required
• This medication is used for the treatment of COVID-19 in adult patients at risk of progression to severe forms of the disease

Change in coverage for some biologic medications in Alberta and Atlantic provinces

• The NIHB Program is changing coverage for certain biologic drugs
• Under the NIHB Biosimilar Policy, clients 19 years of age and older will be required to transition to the biosimilar version of their medication in order to maintain coverage
• Most provincial and territorial drug plans have already implemented similar policies for coverage of biosimilar medications. Aligning NIHB coverage with other public drug plans supports consistent client access to medications and care
• This change will be implemented by the NIHB Program in stages across the country, beginning with Alberta and the Atlantic provinces of Nova Scotia, New Brunswick, Newfoundland and P.E.I.
• Clients in these provinces will have approximately 1 year to transition to the biosimilar version of their medication. As such, they should transition to the biosimilar medication by November 25, 2025 in order to maintain coverage
• This change applies to 3 biologic medications, listed below along with the biosimilar versions:
  • Enbrel® (etanercept) – transition to Brenzys®, Erelzi® or Rymti®
  • Remicade® (infliximab) – transition to Inflectra®, Renflexis™, or Avsola™
  • Rituxan® (rituximab) – transition to Ruxience®, Truxima®, Riximyo®
• Make an appointment to speak with your health care provider if this change applies to you. Pharmacists and prescribers are well informed about biosimilars and will help you transition to a biosimilar medication that's right for you
• Consult the Health Canada website for more information on biosimilar biologic drugs

New delivery policy

• NIHB may cover local delivery, out-of-town delivery, repair-related delivery and delivery of select rental equipment
• Coverage is eligible under certain conditions and when all criteria are met. Prior approval is required
• For more details, see section 1.18 Delivery of the Medical supplies and equipment guide and benefit lists