Non-Insured Health Benefits program updates

COVID-19: NIHB services continue

During the coronavirus outbreak, wait times at some call centres and for some services may take longer than usual. Details on temporary changes related to COVID-19, as well as regular program updates, can be found below.

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

July 2021

Medical supplies and equipment information

Recall of Philips Respironics Positive Airway Pressure (PAP) Equipment

  • NIHB provides coverage of CPAP, BPAP and ventilator devices and supplies listed on the medical supplies and equipment respiratory benefits list
  • Certain Philips Respironics CPAP, BPAP and ventilator devices have been recalled by the company. More information is available on the Government of Canada website
  • NIHB has asked respiratory benefit providers to notify their clients that are affected by the recall and to advise them of next steps
  • If you think you may be affected by the recall and have not been contacted, contact the provider who dispensed your device for inquiries and assistance with the recall process

You are encouraged to contact your physician or health care team who can provide advice on whether to continue or discontinue treatment.

If you are not yet eligible for a new device under NIHB replacement guidelines, your provider can assist you with the process for repair and replacement through Philips Respironics.

The program may consider covering the replacement of your device or providing coverage for a temporary rental device if you are experiencing difficulty with the recall procedures of your equipment. In such situations, please contact your NIHB regional office for assistance.

June 2021

Pharmacy benefit information

New pharmacy benefit listings and changes

  • Trintellix (vortioxetine hydrobromide) is now an open benefit. Prior approval is not required. Trintellix is used in the treatment of major depressive disorder in adults
  • Lonsurf (trifluridine/tipiracil) is now a limited use benefit for treatment of certain cancers. Prior approval is required and coverage criteria can be found in the NIHB drug benefit list
  • The following medications, previously listed as limited use benefits, are now open benefits. Prior approval is no longer required for these medications:
    • Acamprosate (Campral), used for treatment of alcohol use disorder
    • Traditional immunosuppressants – Cyclosporine, Tacrolimus (not including topical), Sirolimus and Mycophenolate
    • Polysaccharide iron complex products – Feramax, Triferexx, Niferex, Polyride-FE, JAMP-Ferrous Polysaccharide

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

  • PrEP can prevent HIV infection for individuals who are at high risk of contracting HIV
  • Tenofovir disoproxil fumarate-emtricitabine (Truvada and generics) can be used for PrEP and is covered as an open benefit. Prior approval is not required.

Dental benefit information

Enrolment of independent dental hygienists in Quebec

  • NIHB welcomes independent dental hygienists in Quebec region to enrol with NIHB for direct billing. Quebec legislation now permits dental hygienists to practice independently and bill for dental hygiene services
  • Dental hygienists can enrol with NIHB in all regions except Prince Edward Island and the Territories, where professional regulations do not currently allow dental hygienists to practice independently

General program information

Submitting client reimbursement requests to Express Scripts Canada

  • Express Scripts Canada processes NIHB client reimbursement claims for pharmacy, dental, medical supplies and equipment, vision care and mental health counselling benefits
  • Find instructions and the list of documents required for each benefit type on the Express Scripts Canada NIHB website
  • Client reimbursement requests can be submitted to Express Scripts Canada by mail, fax or online through your NIHB client web account
  • If you are submitting a client reimbursement request through your web account:
    • You must attach at least 1 document such as a receipt, prescription, or explanation of benefits from other plans. Clear photos are acceptable
    • Ensure that you have all required documents ready to upload before you submit
    • Once ESC has received and entered the claim for reimbursement, you can view the status in your web account under 'claims history'
    • Claims received and in progress will show as registered. When the claim has been adjudicated, the claim status will show as approved, paid, or rejected
    • You can submit a client reimbursement request for a child under the age of 16 through your web account if you are the parent or guardian, however you will not be able to view the claim status through your account. If the child does not have their own web account, you can contact Express Scripts Canada to check on the status of the claim
  • If you are submitting a client reimbursement request by mail or fax:
    • The NIHB Client Reimbursement form must be completed and all required documents included. You can find the form and instructions here
    • Make sure to include your correct address and telephone number, and don't forget to sign and date the form
    • Once the claim has been processed, you will receive a claim statement by mail. You can also view claim status and statements online through your client web account, if you have one
  • Whether you submit your client reimbursement request by mail, fax or through your web account, you can sign up for direct deposit by filling out the NIHB communication preference and direct deposit form, located here
  • Payment to someone other than the client, such as to a parent or legal guardian for their child's claim, can only be made by cheque
  • If information is missing from your client reimbursement request, you will be contacted by Express Scripts Canada. You may be asked to re-submit the claim
  • If you have any questions about client reimbursement for NIHB pharmacy, dental, medical supplies and equipment, vision care or mental health counselling benefits, please contact Express Scripts Canada
  • Claims for medical transportation benefits are processed by the NIHB Program through Indigenous Services Canada's regional offices. More information on NIHB client reimbursement is available here

March 2021

Pharmacy benefit information

New pharmacy benefit listings

  • Emerade (epinephrine bitartrate) is now covered as an open benefit (prior approval not required). Emerade is an adrenaline auto-injector used for the emergency treatment of severe allergic reactions
  • Humira (adalimumab) 20 mg/0.2 mL injection is now covered as a limited use benefit with prior approval, for treatment of:
    • pediatric Crohn's disease
    • polyarticular juvenile idiopathic arthritis in children 2 to 17 years
  • Check the NIHB drug benefit list for listings and coverage criteria

Medical supplies and equipment (MS&E) information

Coverage for walker accessories

Dental benefit information

Expanded coverage for crowns

  • As of April 1, 2021, the NIHB program will expand coverage for crowns on second molars
  • Crowns on second molars will be eligible for coverage whether the first molar is present or not, if all other coverage criteria are met
  • Find the complete crown policy in the NIHB dental benefits guide

Vision care benefit information

Understanding vision care benefit frequency

  • The NIHB program's vision care benefit provides coverage for eligible eye exams and corrective eyewear
  • Under the NIHB vision care policy, the frequency guidelines are:
    • children 0 to 17 years are eligible once a year
    • clients 18 years and older are eligible once every two years
  • Frequency of coverage is calculated by calendar year only, not months and days
    • For example, for a two-year frequency, if you receive coverage for new eyewear at any time in 2019, you will be eligible again starting on January 1, 2021
  • Frequency for eye examinations and eyewear is determined by the last date of service
  • For eye examinations, the date of service is the date you had the exam
  • For services requiring more than one appointment, the date of service is the date when the service was completed
  • For eyewear, such as eyeglasses or contact lenses, the date of service is the date you picked up the eyewear or the date the provider shipped it to you
    • For example, for a one-year frequency, if you ordered glasses in December 2020 and picked them up in December 2020, you used your coverage for 2020. However, if you picked up the glasses in January 2021, you used your coverage for 2021.
  • Clients with specific medical needs may qualify for more coverage, such as reimbursement amount or frequency, on an exception basis. Refer to the NIHB guide to vision care benefits
  • If you need more information on your frequency for vision care benefits, call your NIHB regional office for assistance

Vision care provider billing

  • Many vision care providers are enrolled with NIHB and reimbursed directly by the program for eligible benefits provided to NIHB clients
  • NIHB will reimburse providers up to maximum coverage rates established by the program
  • Before you receive any vision care services, NIHB recommends that you speak with your provider's office to confirm that:
    • the provider is enrolled with NIHB and will bill the program directly
    • the item or service is fully covered by NIHB
    • the provider will not charge you any additional fees
  • If your provider does not bill NIHB directly, you can contact your NIHB regional office for assistance to find an alternate provider

January 2021

Pharmacy benefit information

New coverage for Shingrix

  • As of January 11, 2021, the Shingrix vaccine is covered by NIHB as a limited use benefit
  • Shingrix is a vaccine to prevent shingles, which causes a painful rash and can be severe in some people
  • Shingles is caused by the re-activation of the virus that causes chickenpox. The risk of shingles is higher in seniors and in people with weaker immune systems
  • The vaccine is given in two doses, 2 to 6 months apart
  • Prior approval is not required for clients between 65 and 70 years of age
  • Shingrix is also included on the Formulary for adjunct medications used during active cancer treatment. Clients that have received approval for any medication on this formulary will be automatically approved for Shingrix
  • For clients who have other serious health conditions that weaken their immune system, NIHB will consider coverage on an exception basis
  • If your doctor prescribes the Shingrix vaccine for you, you'll need to get it from the pharmacy. Pharmacists should call the NIHB DEC to request prior approval, if required
  • In most provinces and territories, the Shingrix vaccine can often be administered in pharmacies and pharmacists can bill NIHB for an injection fee. Contact your pharmacy to confirm that they have it in stock and if they can administer the injection
  • If you are unable to have the vaccine administered at a pharmacy, ask your health care provider about other options
  • To maximize the protection offered by Shingrix, it is important that you get both doses. When you get your first dose, ask your doctor or pharmacist to schedule your next dose

Other new pharmacy benefit listings

  • Mezera 1 gram rectal foam (mesalazine) is available as an open benefit, so prior approval is not required. This medication is used for treatment of inflammatory bowel disease
  • Ziextenzo (pegfilgrastim) 10mg/mL injection is listed as an open benefit. This medication is used to prevent infection in clients receiving certain types of cancer treatment
  • Fast-acting dextrose products, Dex-4 Glucose Liquiblast and Dex-4 Glucose Gel are now available as open benefits, in addition to BD Glucose and DEX-4 Glucose tablets. These products are used to quickly raise blood sugar levels for diabetic clients
  • Prevymis (letermovir) vials and tablets are limited use benefits, with prior approval required, for the prevention of cytomegalovirus (CMV) infection in adult clients who have received bone marrow transplants
  • Riximyo (rituximab) 10 mg/mL injection is a limited use benefit for treatment of severe rheumatoid arthritis

Reminder: non-prescription products recommended by pharmacists

  • Under the NIHB pharmacy prescriber policy, pharmacists and other health professionals can recommend non-prescription drugs and health products that are eligible for coverage as NIHB pharmacy benefits and listed on the NIHB drug benefit list
  • Previously, NIHB had a list of selected non-prescription items that could be recommended by a pharmacist. That list is no longer in effect, and is replaced by this new policy
  • This means you don't need a prescription from a doctor for coverage of non-prescription items on the NIHB drug benefit list
  • A few examples of products that can be recommended by pharmacists for NIHB coverage are:
    • smoking cessation products
    • vitamins
    • non-medicated emollient creams, such as Glaxal Base and similar products, for the treatment of eczema. Prior approval is required
  • Check the NIHB drug benefit list to find eligible pharmacy benefits covered by NIHB, as well as any criteria for coverage

Medical supplies and equipment (MS&E) information

Augmentative and alternative communication benefits

  • Augmentative and alternative communication (AAC) benefits are now listed as MS&E benefits
  • These devices and supplies are used to supplement or replace natural speech when clients have a significant speech impairment
  • AAC benefits covered by NIHB include:
    • quick messaging devices
    • speech-generating devices (SGD)
    • communication display boards and software
    • integrated and complex systems
    • software
    • switches and mounting systems
    • accessories
  • Find more information in the communication aids benefits list

Non-implantable bone conduction hearing systems

  • Non-implantable bone conduction hearing systems are now a limited use benefit
  • These products may be used by clients with conductive hearing loss that isn't helped by regular hearing aids
  • Find more information in the audiology benefits list

Reimbursement for gloves

  • NIHB covers latex and vinyl gloves as open benefits, up to 12 boxes per year
  • Providers can bill NIHB, or NIHB will reimburse clients up to $13.75 for one box of 100 gloves in all provinces, and $15.80 in the Territories
  • Gloves are covered with a prescription from a physician or a nurse practitioner, or a written recommendation from a registered nurse
  • Find more information in the medical surgical supplies and equipment benefit list

Vision care benefit information

Temporary coverage of shipping during COVID-19

  • As a temporary measure, vision care providers can bill NIHB for the cost of shipping eligible eyewear to clients who are unable or prefer not to visit the retail location
  • Let your eyewear provider know if you'd like the item shipped to you so they can include the shipping cost in the prior approval request to NIHB

General program information

NIHB clients in British Columbia

  • In BC, the First Nations Health Authority (FNHA) provides health benefit coverage for First Nations people who are BC residents
  • The NIHB program continues to provide coverage and services for Inuit in BC, as well as First Nations who are not BC residents
  • If you are an NIHB client in BC and need help finding a benefit provider, please call NIHB at 1-800-232-7301 for assistance
  • Many providers in BC are enrolled with NIHB to provide benefits and bill the program directly, however they may not see many NIHB clients
  • NIHB recommends that you contact the provider's office before you visit to let them know that you are an NIHB (not FNHA) client, and confirm that they can bill NIHB directly for eligible products and services provided to you

October 2020

Pharmacy benefit information

Update on coverage of rituximab

  • Rituximab is a type of medication used to treat some autoimmune conditions. Previously, the only rituximab product reimbursed by NIHB was Rituxan
  • NIHB has recently listed a second rituximab product, Truxima
  • Truxima was approved by Health Canada as 'biosimilar' to Rituxan, which means that these medications work in the same way and have similar effectiveness
  • Adult clients with new prescriptions for a rituximab medication who meet NIHB's coverage criteria will be covered for Truxima (instead of Rituxan) for treatment of rheumatoid arthritis, granulomatosis with polyangiitis (GPA) or microscopic polyangiitis (MPA)
  • Clients who are already taking Rituxan will continue to be covered for their current medication

Medical supplies and equipment (MS&E) information

  • The MS&E policy guide and benefits lists have been combined so that information about eligible benefits and coverage policies can be found together
  • The following MS&E coverage changes came into effect on October 7, 2020:

Dental benefit information

New coverage for preventive dental services

  • NIHB added new coverage for preventive dental services
  • Topical treatments such as silver diamine fluoride are applied to damaged areas on the surface of the teeth to prevent the progression of cavities
  • These are called remineralization or antimicrobial treatments, and are now covered by NIHB without predetermination:
    • 3 times per 12 months for clients under 17 years of age
    • once per 12 months for clients 17 and older

August 2020

Pharmacy benefit information

New pharmacy benefit listings

  • NIHB now covers 3 Voltaren Emulgel products for treatment of back, muscle or joint pain. Eligible products listed in the NIHB drug benefit list are covered without prior approval, up to 100 grams per month
  • NIHB recently listed triamcinolone hexacetonide, a steroid used to reduce swelling caused by a variety of health conditions including allergies, asthma or rheumatoid arthritis
    • The program now covers both injectable forms of the medication, triamcinolone hexacetonide and triamcinolone acetonide, as open benefits

Coverage of non-prescription pharmacy benefits recommended by pharmacists

  • NIHB now accepts a pharmacist's recommendation for coverage of any eligible non-prescription 'over-the-counter' pharmacy benefit
  • To be eligible for coverage, the item must be listed on the NIHB drug benefit list and within the pharmacist's scope of practice to recommend or prescribe
  • Previously, NIHB had a selected list of non-prescription items that could be recommended by a pharmacist. That list is no longer in effect, and is replaced by this new policy

New dose limit for gabapentin

  • For client safety, NIHB has changed the dose limit for coverage of gabapentin to 3600 milligrams per day, to a maximum of 30 days
  • Pharmacists should call the Drug Exception Centre if a client reaches the dose limit

Medical supplies and equipment information

New coverage for oral digital thermometers

  • During the COVID-19 pandemic, oral digital thermometers are listed as an open benefit with a price limit of $25 and a replacement guideline of 1 per 5 years
  • Thermometers are covered with a prescription from a physician or a nurse practitioner, or a written recommendation from a registered nurse or a pharmacist

Reminder: coverage of electric breast pumps

  • Electric breast pumps are a limited use benefit and prior approval is required for coverage. Criteria for coverage can be found in the MS&E guide and benefit lists
  • During the COVID-19 pandemic, electric breast pumps may be covered for purchase (instead of rental), once every 3 years at a maximum price of $275.00

Increased coverage for some communication and respiratory benefits

  • NIHB recently changed frequency guidelines for selected voice restoration products and supplies. Prior approval is required and the new frequency guidelines are:
    • puncture dilator: 1 per year
    • gel cap insertion system: 1 per year
    • plug insert: 2 per year
    • flushing device: 1 box per year
    • cleaning brush: 2 boxes per year
    • gel cap: 1 box per year
  • The replacement guideline for inlet filters has increased to 14 filters per year
    • Inlet filters are used with home positive airway pressure (PAP) devices and are covered as open benefits

July 2020

NIHB launches new claims processing system and services via Express Scripts Canada

NIHB is pleased to announce that new and improved claims processing services for clients and providers are now available through Express Scripts Canada.

About Express Scripts Canada

  • Express Scripts Canada is a private sector company that provides electronic claims processing services through a system that is tailor-made for NIHB
  • Express Scripts Canada has processed NIHB dental, pharmacy and medical supplies and equipment benefit claims since 2009
  • Express Scripts Canada now also provides claims processing services for vision care and mental health counselling benefits
  • Express Scripts Canada does not process any aspects of NIHB medical transportation benefits, which continue to be administered by NIHB through Indigenous Services Canada's regional offices, First Nations communities, or territorial governments (NWT and Nunavut)
  • NIHB maintains full responsibility for benefit coverage policies and decisions on client claims, and continues to review requests for benefits that require prior approval or predetermination
  • If you need assistance or more information about any services provided by Express Scripts Canada, contact the NIHB Client Call Centre at Express Scripts Canada from Monday to Friday between 6:30 a.m. and 8:30 p.m., Eastern Time, excluding statutory holidays

NIHB client web accounts

  • NIHB clients now have the option of creating a secure, web-based personal client account through the Express Scripts Canada NIHB website
  • By creating a secure NIHB client web account, clients can:
    • view their benefit claims history and status of pending requests
    • submit client reimbursement requests online
    • submit appeal requests online
    • receive NIHB communication directly by email
  • To create a web account:
  • If you need help with this process, you can contact the NIHB Client Call Centre at Express Scripts Canada
  • The creation of a web-based account is not mandatory
  • You can still correspond with NIHB or Express Scripts Canada by mail, fax or telephone

New client reimbursement process

  • Client reimbursement requests for the following will now be processed by Express Scripts Canada:
    • pharmacy
    • dental
    • medical supplies and equipment
    • vision care
    • mental health counselling benefits
  • The NIHB Client reimbursement page of the Express Scripts Canada NIHB website provides the form and instructions to submit client reimbursement requests, including what supporting documents are required for each benefit type
  • There are 3 ways to submit a client reimbursement request to Express Scripts Canada:
    • by mail
    • by fax
    • online through your new NIHB client web account
  • If you are submitting your client reimbursement request online through your NIHB client web account, you can send all documents electronically
  • A scanned copy or photo of supporting documents, such as receipts, can be accepted

New online drug benefit list

  • The NIHB drug benefit list is a listing of prescription and over-the-counter medications and products that are covered by NIHB
  • A new and improved online drug benefit list is now available on the Express Scripts Canada NIHB website. It is easier to search, and new listings are added right away
  • For best results, search medications or products by chemical name, for example, 'ibuprofen', not 'Advil'. You will get a list of results, with an option to View details to see listing status and criteria, if applicable, for each product
  • Please continue to contact the NIHB Drug Exception Centre for questions about pharmacy benefits

Please visit the Express Scripts Canada NIHB website for more information and to access these new features and services.

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