Non-Insured Health Benefits program updates

New pharmacy benefit listings

Check the drug benefit list to find all eligible products and criteria for coverage

• Neomycin compounded capsules are now covered as an open benefit without prior approval. This medication is an antibiotic used to treat skin infections
• The following new listings are covered as limited use benefits with prior approval:
  • Vascepa (icosapent ethyl) to reduce the risk of cardiovascular events for patients also taking medication for high cholesterol
  • MAR-Trientine (trientine hydrochloride) used for the treatment of Wilson's disease for patients who are intolerant to penicillamine
  • Kynmobi (apomorphine) sublingual film tablets for the acute, intermittent treatment of patients with Parkinson's disease
  • Eylea (aflibercept) prefilled syringe for the treatment of some types of macular degeneration and diabetic eye disease
  • Onureg (azacitidine) tablets for the treatment of adult patients with acute myeloid leukemia (AML)
  • Inrebic (fedratinib) for treatment of an enlarged spleen, and disease-related symptoms for adult patients with some types of cancer
  • Trikafta (elexacaftor-tezacaftor-ivacaftor) for the treatment of cystic fibrosis in patients aged 6 years and older
  • Erivedge (vismodegib) for the treatment of certain skin cancers
  • Breztri Aerosphere (budesonide/glycopyrronium/formoterol fumarate), an inhaler for the treatment of chronic obstructive pulmonary disease (COPD), including chronic bronchitis and/or emphysema
  • Enspryng (satralizumab) for the treatment of neuromyelitis optica spectrum disorder (NMOSD) in patients aged 12 years or older

Coverage for insulin pumps

• NIHB provides coverage of insulin pumps and supplies for NIHB clients with type 1 diabetes. Prior approval is required
• Insulin pumps covered include:
  • YpsoPump (Ypsomed)
  • MINIMED 770, 670 and 630 (Medtronic)
  • t:slim X2 (Tandem)
• Full coverage criteria are noted in the Drug Benefit List

Reminder: coverage for smoking cessation treatments

• Smoking cessation therapies are used to help people quit smoking. NIHB clients are eligible in a 12-month period for coverage of:
  • Patches, gums, lozenges, inhalers or spray
  • Zyban – 360 tablets per year
  • Champix – 330 tablets per year
• Some people need more than one form of treatment at a time to control cravings. NIHB will cover these products when used together, or separately
• Talk to your health care provider about the right product, or combination of products, that is best for you

Expanded pediatric hearing aid warranties

• As of November 15, 2022, the eligibility for pediatric hearing aid warranties applies to clients under 18 years of age (a change from under 16 years of age previously)
• Find more information in section 2.1.5 Warranties of the Audiology equipment and supplies benefits list. Your provider can confirm if you meet the criteria for warranty coverage

Increased coverage for eye exams for clients 65 and older

• Starting January 1, 2023, clients age 65 and older are eligible for coverage of an eye exam every year, if the exam is not covered by a provincial or territorial health plan
• If your province or territory covers eye exams for seniors age 65 and older every two years, you may use NIHB coverage during the gap year
  • for example, if you are eligible for provincial coverage in 2022 and 2024, you can use NIHB coverage in 2023
• Contact your NIHB regional office if you have questions about your coverage for eye exams

Mental health telecounselling

• Many mental health counselling providers offer counselling services by phone or video call, and these services are covered by NIHB
• Your first session with a mental health counselling provider should generally be in person, so you and your provider can discuss a treatment plan and decide whether in-person or telecounselling is best for you
• Medical transportation support is available, if needed, to the nearest appropriate provider
• If you choose mental health telecounselling, NIHB recommends that you work with a provider whose office location would be eligible for medical transportation support in case you want to switch to in-person services
• More information on NIHB coverage of mental health telecounselling is available in Appendix B of the Guide to mental health counselling benefits

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 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
• 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 your NIHB regional office or the Dental predetermination centre (for dental or orthodontic services) for assistance to find an alternate provider

Coverage of compounded pediatric acetaminophen and Ibuprofen

• There is a current shortage of over-the-counter pain and fever medications (oral liquid acetaminophen and ibuprofen) for infants and children across Canada
• To help address the current shortage, NIHB will cover compounded acetaminophen and ibuprofen oral liquids
  • Compounded medications are prepared by a pharmacist using the same active ingredients as the manufactured drug product. Check with your pharmacy to see if they offer this service
• Speak to your pharmacist about other appropriate forms of these medications that may be available such as chewable tablets or suppositories
• If you or your pharmacist have any questions, please contact the NIHB Drug Exception Centre

New pharmacy benefit listings

• Check the Drug Benefit List to find all eligible products and criteria for coverage
• Entuzity KwikPen, a high concentration insulin pen, is now covered as an open benefit without prior approval
• The following new listings are covered as limited use benefits with prior approval: 
  • Mayzent for the treatment of secondary progressive multiple sclerosis
  • Kesimpta for the treatment of adult patients with relapsing-remitting multiple sclerosis
  • Evrysdi for the treatment of 5q spinal muscular atrophy
  • Riabni for the treatment of rheumatoid arthritis, granulomatosis with polyangiitis and microscopic polyangiitis. Riabni is a biosimilar to Rituxan (the reference biologic drug)

Coverage for fertility medications

• NIHB will now consider coverage on a case-by-case basis for medications used for assisted fertility treatments. Previously, these were exclusions of the program
• This coverage is for medications only.  Other services and procedures related to fertility treatment may be covered or supported by provincial and territorial programs
• Fertility treatment is an area that is evolving, so a variety of different medications may be prescribed.  For this reason, not all medications used as part of a fertility treatment are listed in the NIHB drug benefit list
• Pharmacy providers should call the Drug Exception Centre (DEC) to initiate a request for coverage of prescribed fertility medication

New coverage for specialized feeding supplies

• Specialized feeding bottles and teats have been added as limited use benefits with prior approval:
  • 8 bottles with teats are covered every 6 months
  • 4 replacement teats are covered every 3 months
• These items are used by children with complex feeding needs due to conditions like dysphagia, cleft palate or other craniofacial anomalies
• For more information, check the Self-care equipment and supply benefits list

Low vision aid prescribers

• The following types of health professionals are now recognized by NIHB to prescribe low vision aids:
  • low vision specialists (LVS)
  • registered nurses (RNs)
  • nurse practitioner (NP)
  • physicians (MDs)
• More information can be found in the Low vision equipment and supplies benefits list

Reminder: submitting dental benefit appeals

• 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
  • an NIHB client can authorize someone to act as a representative on their behalf.  This authorization must be in writing and signed by the client
• Services identified as exclusions under the NIHB program will not be considered for appeal
• There are three levels of appeal available. Each level of appeal must include a dated and signed appeal letter from the client, parent, legal guardian or authorized client representative, which includes the client's:
  • name
  • date of birth
  • identification number
• If an appeal letter is not included in the submission, the appeal cannot be processed
• All appeals must include supporting documentation from the treating dental provider, such as:
  • current (within the last 12 months) X-rays
  • treatment plan
  • clinical findings and notes to support the request 
• Label your envelope 'APPEAL-CONFIDENTIAL' and mail it to the Dental predetermination centre, using the correct mailing address for either dental or orthodontic services
• For more information on the dental appeal process, please see  Appendix D 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

Updated Guide to mental health counselling benefits

• NIHB recently updated the Guide to mental health counselling benefits to clarify some policies and processes
• Section 3.2.1 Finding a provider and accessing services, was added to provide helpful information on getting started
• Appendix A lists all types of mental health counsellors that are eligible to provide services under NIHB, by province and territory. Health professions are regulated separately by each province and territory, so NIHB provider eligibility reflects these differences
• Section 3.4 clarifies types of counselling eligible for coverage:
  • assessment sessions of up to two hours may be initiated by an eligible provider without prior approval, to plan a course of treatment for the client
  • individual counselling is provided on a one-on-one basis. If another person participates (such as a family member, in a support or information-providing role), there should be no additional charge for the other participant
  • group counselling, up to a maximum of 8 eligible NIHB clients, where all clients participate in active counselling. This can include family counselling
• Coverage is provided for eligible NIHB clients only. If a participant in a group counselling session is not an eligible client, their counselling cannot be billed to the NIHB program
• For complete information, please visit the Guide to mental health counselling benefits

Coverage for unregistered children under 2 years

• In order to allow time for parents to register their children for First Nation status or with their Inuit land claim organization, NIHB provides coverage for unregistered children with at least one NIHB-eligible parent
• NIHB now covers unregistered children up to 2 years of age (extended from 18 months, previously) if they have a parent or guardian who is NIHB eligible
• Some types of benefits may require a temporary client ID number
• If your unregistered children requires access to benefits, please contact the NIHB program
• Parents or guardians should begin the application process for First Nation status or recognition by an Inuit land claim organization as soon as possible and well in advance of their child's second birthday
  • Applications for First Nation status take 6-8 months to process (on average), and may take longer in some cases
  • for information on First Nation registration, visit Indian status
  • for information on Inuit beneficiary enrollment, contact your land claim organization

New pharmacy benefit listings

Check 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:

• Duobrii (halobetasol/tazarotene) lotion for the treatment of moderate to severe plaque psoriasis
• GE200 Blood Glucose Test Strips, within program quantity limits
• Durezol (difluprednate) eye solution to reduce inflammation after cataract surgery
• Lotemax (loteprednol) eye solution, gel and ointment to reduce inflammation after cataract surgery
• Prolensa (bromfenac) eye solution to reduce pain and inflammation after cataract surgery

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

• Osnuvo (teriparatide) injection for the treatment of osteoporosis. Osnuvo is a biosimilar to Forteo (the reference biologic drug)
• Cabometyx (cabozantinib) tablets for the treatment of liver cancer
• Ajovy (fremanezumab) for the prevention of migraine in adults who meet certain medical criteria
• Calquence (acalabrutinib) for treatment of chronic lymphocytic leukemia in adults
• Atectura Breezhaler (indacaterol/mometasone furoate) for the treatment of asthma in patients aged 12 years and older
• Enerzair Breezhaler (indacaterol/glycopyrronium/mometasone furoate) for the treatment of asthma in patients who meet certain medical criteria
• Beovu (brolucizumab) for the treatment of certain types of macular degeneration
• Ilumya (tildrakizumab) injection for the treatment of moderate to severe plaque psoriasis
• Crysvita (burosumab) for the treatment of X-linked hypophosphatemia (XLH)
• Riabni (rituximab) for the treatment of rheumatoid arthritis, granulomatosis with polyangiitis and microscopic polyangiitis. Riabni is a biosimilar to Rituxan (the reference biologic drug)
• Mayzent (siponimod) for the treatment of secondary progressive multiple sclerosis

Increased coverage for Champix and Zyban

• NIHB now covers the following amounts for these smoking cessation products:
  • Champix – increased to 330 tablets per year
  • Zyban – increased to 360 tablets per year
• The one year period begins on the date the first prescription is filled
• NIHB accepts prescriptions from pharmacists for Champix and Zyban, if this is within their provincial/territorial scope of practice

Eligible nutrition products recommended by dietitians

• NIHB covers selected nutrition products (infant formula or nutritional supplements) when medically necessary, with prior approval
• NIHB accepts recommendations from dietitians for eligible nutrition products, if this is within their provincial/territorial scope of practice
• You may obtain a prescription or a recommendation for nutrition products from a physician, nurse practitioner or dietitian (where allowed)
• Check the drug benefit list to find eligible products and coverage criteria

COVID-19 temporary policy changes: update

• As of July 1, 2022, temporary COVID-19 policies related to MS&E benefits will end
• Normal program requirements for prescriptions will be in effect for MS&E benefits. For replacement of equipment or supplies, prescriptions must not be older than one year for most benefits
• Some temporary COVID-19 changes will become permanent Program policy, in full or with modifications. These are described in the articles that follow
• Refer to section 1.0 General policies of the Medical supplies and equipment guide and benefit lists for all current policies

Coverage of oral digital thermometers

• Oral digital thermometers will continue to be covered as open benefits, at a cost of up to $16 once every 5 years
• They are covered with a prescription from a doctor or nurse practitioner, or a recommendation from a registered nurse or licensed/registered practical nurse

Requests for supplemental home oxygen

• As of July 1st, 2022, all requests for supplemental home oxygen (initial or renewal) will again require testing
• Either an arterial blood gas (ABG) or an oximetry test is required for coverage of oxygen
• For supplemental home oxygen renewal, a respiratory therapist or registered nurse can request a change in oxygen equipment or in the quantity being requested. A written explanation for the change must be provided with the request

Coverage of tele-audiology

• Providers who are equipped for tele-audiology may continue to perform these services virtually for clients who live in remote areas:
  • fitting and dispensing of hearing devices
  • hearing device performance check and readjustment

Expanded eligibility for hearing aids

• NIHB has expanded eligibility for hearing aids to cover adults with a wider range of hearing loss
• Your provider can confirm if you meet the criteria for coverage

Coverage changes for eye prosthesis

• The recommended replacement guideline for eye prostheses was changed to 5 years (from 3 previously) because adjustment services are now covered to adapt the prosthesis to changes in the eye socket over time
• The recommended frequency guideline for polishing was increased to 2 times per year
• Conformers are now covered. These are temporary shells used to hold the shape of the eye socket before fitting the prosthesis
• Optometrists were added as prescribers of eye prosthesis
• Ocularists can now recommend replacement of eye prosthesis

Understanding your dental predetermination letter

• Some dental and orthodontic services require predetermination, or prior approval, to confirm eligibility for NIHB coverage. For these services, your dental provider will submit a predetermination request to the NIHB Dental Predetermination Centre (DPC)
• Once NIHB has reviewed the request, you and your dental provider will receive a predetermination letter from the NIHB DPC to let you know the result. The predetermination request may be
  • approved (showing eligible amount)
  • on hold requiring additional information
  • denied
• Important information on the result, such as what information is missing if the request is on hold, can be found in the Predetermination Line Level Messages section at the bottom of the predetermination letter
• When you receive a predetermination letter, contact your dental provider's office to schedule the service or discuss next steps
• If you have any questions about a predetermination letter, call the NIHB Dental Predetermination Centre at 1-855-618-6291 (dental services) or 1-866-227-0943 (orthodontic services)

Client mailing address

• In order to receive important mail from NIHB, such as predetermination letters or client reimbursement cheques, your mailing address must be up to date
  • if you have an NIHB client web account through Express Scripts Canada, you can update the address in your profile
  • if you do not have a client web account, call Express Scripts Canada at 1-888-441-4777 to update your mailing address

New pharmacy benefit listings

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

• Aermony Respiclick (fluticasone propionate) inhalers, used daily to decrease asthma attacks
• Foquest (methylphenidate hydrochloride) time release capsules for the treatment of Attention Deficit Hyperactivity Disorder (ADHD)
• Nexplanon (etonogestrel), a hormonal birth control implant
• Nyvepria (pegfilgrastim), used to increase white blood cells for patients receiving chemotherapy
• Vocabria (cabotegravir) and Cabenuva (cabotegravir-rilpivirine) for the treatment of adult clients with stable, suppressed HIV

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

• Baqsimi (glucagon) nasal powder for the treatment of severe hypoglycemia reactions for clients on insulin
• Kalydeco (ivacaftor), Orkambi (ivacaftor/lumacaftor) for the treatment of cystic fibrosis
• Olumiant (baricitinib) for the treatment of moderate to severe rheumatoid arthritis
• Rozlytrek (entrectinib) for the treatment of advanced or metastatic non-small cell lung cancer
• Zejula (niraparib) for the maintenance treatment of ovarian, fallopian tube, or primary peritoneal cancer after chemotherapy
• Vyndaqel (tafamidis meglumine) for the treatment of adult patients with cardiac disease caused by transthyretin amyloid cardiomyopathy

Check the NIHB drug benefit list for complete listings and coverage criteria.

Sublocade now covered without prior approval

• Sublocade is a monthly injection used for the treatment of opioid use disorder
• NIHB now covers Sublocade without prior approval
• Sublocade is most effective when used as part of an opioid treatment program that includes counselling and support
• Prescribers need special certification for Sublocade and it must be injected by a trained healthcare provider
• Talk to your healthcare provider about whether this medication is right for you and how it will be administered
• As a reminder, Suboxone and methadone are also covered for the treatment of opioid use disorder without prior approval
• Clients who receive coverage for these medications will be enrolled in the NIHB client safety program

Coverage of gauze packing strips for wound care

• NIHB now covers up to 40 bottles per year of regular gauze packing strips
• Prior approval is not required within program price and replacement guidelines
• Find more information in section 13.4 Wound care of the Medical surgical equipment and supplies benefit list

Medical equipment covered by another benefit plan

• NIHB may cover supplies, maintenance, or repairs of medical equipment that was covered by another benefit plan or purchased by the client, if:
  • the equipment is an eligible benefit under NIHB, and all policies and criteria for coverage of the item are met
  • the supplies, maintenance, or repairs are not covered by another benefit plan
• Information normally required for prior approval of the item, such as testing or assessment information, diagnosis, device make and model, and medical justification, must be submitted along with proof of other coverage or purchase
• The coverage of supplies, maintenance, and repairs follows the policies set out in section 1.0 General policies of the Medical supplies and equipment guide and benefit lists

Client web accounts

• NIHB clients now 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 for these benefits
• 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 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 Express Scripts Canada's NIHB call centre at 1-888-441-4777 for assistance

Payment by direct deposit

• If you have submitted a claim for client reimbursement, you can receive payment through direct deposit into your bank account. This is the fastest and most secure way to receive payment
• To enroll with Express Scripts Canada for direct deposit:
  • send a completed copy of the Direct Deposit and Communication Preference Form for NIHB Clients. The form is found at the bottom of the client reimbursement page
  • provide a void cheque or bank letter, and include your contact information in case there is a need to contact you about your payment
• Claim payments are made by Express Scripts Canada every two weeks. Once the claim is processed, clients who are enrolled for direct deposit will receive payment on these dates
  • direct deposit is not available for payment to someone other than the client, such as to a parent for their child's claim, or to a client under 16 years of age. These payments can only be made by cheque
• Claims for medical transportation benefits are processed by the NIHB program through Indigenous Services Canada's regional offices. For reimbursement of medical transportation benefits, fill out and return the Indigenous Services Canada direct deposit form
• If you can't receive payment through direct deposit, you can receive payment by cheque. Be sure to include your mailing address when you send your client reimbursement request

How to find an enrolled provider

• Many providers of non-insured health benefits are enrolled with NIHB to bill the program directly for eligible items or services provided to clients
• To find an enrolled provider in your area, please contact:
  • your NIHB regional office for medical supplies and equipment, vision care or mental health counselling providers
  • the Drug Exception Centre for pharmacy providers
  • the Dental Predetermination Centre for dental and orthodontic providers
• You may also contact an NIHB Navigator in your region for assistance finding an enrolled provider
• Express Scripts Canada is not able to help you find an enrolled NIHB provider, and will transfer or refer you to an NIHB call centre

Drive Medical Canada recall of bed assist handles and rails

• Drive Medical Canada has recalled 4 models of home bed assist handles and rails
• The manufacturer and Health Canada both recommend that clients immediately stop using the recalled devices due to a risk of getting trapped between the bedrails, mattress and bedframe
• More information on the recall can be found on the Government of Canada's Recalls and safety alerts page: Home Bed Assist Handles recalled due to potential entrapment hazard
• Home bed assist handles and rails are affixed alongside a mattress on home-style beds to help people getting into and out of bed. NIHB refers to them as 'bed grab bars'. They are covered as open benefits within Program price and replacement guidelines
• If you have a bed grab bar, the provider who dispensed it should know the make and model of the device and if it's affected by the recall. Providers are expected to notify affected clients and inform them of next steps
  • if you have not been contacted by your provider and are unsure if your device is affected, contact your provider to find out
• Providers must take steps to replace the recalled device with one that is safe and effective
• If you are renting a bed grab bar affected by the recall, your provider should switch it for a similar device that is safe
• If you are using a recalled bed grab bar that was purchased, it may be eligible for early replacement through NIHB. Your provider should submit a completed prior approval request to the NIHB regional office
• If you are using a recalled grab bar that is already eligible for replacement, no prior approval is required for a new grab bar that is within NIHB pricing. These devices are covered by NIHB for replacement every ten years