Non-Insured Health Benefits program updates

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:

• Elonox (enoxaparin sodium) injections for deep vein thrombosis and ischemic cardiac disease
• Zincofax (zinc oxide) 15% cream for diaper rash and minor skin irritations
• Cuvposa (glycopyrrolate) oral liquid to reduce chronic severe drooling in children

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

• Emgality (galcanezumab) for the treatment of episodic or chronic migraines
• Vitrakvi (larotrectinib) for the treatment of some cancerous tumours in adults and children
• Ngenla (somatrogon) for the long-term treatment of children who have a growth hormone deficiency
• Bimzelx (bimekizumab) 160 mg/mL pre-filled syringe injection and auto-injector for the treatment of moderate to severe plaque psoriasis in adults
• Ruzurgi (amifampridine) tablets for the treatment of Lambert-Eaton Myasthenic Syndrome (LEMS)
• Brukinsa (zanubrutinib) capsules for the treatment of adults with Waldenström macroglobulinemia (WM)
• Oralair (grass pollen allergen extract) tablets for the treatment of grass pollen allergies, if other medications haven't worked
• Rupall (rupatadine) 10 mg tablet and 1mg/ml oral solution antihistamine for clients who can't take other antihistamines
• Blexten (bilastine) tablet or oral solution antihistamine for clients who can't take other antihistamines
• Biphentin (methylphenidate hydrochloride) for the treatment of Attention-Deficit Hyperactivity Disorder (ADHD)
• Intuniv (guanfacine hydrochloride) for the treatment of Attention-Deficit Hyperactivity Disorder (ADHD)

Coverage change for Shingrix

• NIHB now covers Shingrix as an open benefit for clients 60 years and older. It was previously listed as an open benefit for clients 65 years and older
• NIHB continues to consider coverage for immunocompromised clients under 60 years of age on an exceptional basis (prior approval required)
• Shingrix is a vaccine to prevent shingles, which is caused by the re-activation of the virus that causes chickenpox
  • Shingles causes a painful rash and can be severe in some people
  • The risk of shingles is higher in seniors and in people with weaker immune systems
• The vaccine is given in 2 doses, from 2 to 6 months apart. 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
• 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 first 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

Change of listing status for certain items

• NIHB changed the listing status to open benefit for some self-care and mobility items
• Prior approval is no longer required for coverage of these items:
  • specialized crutches
  • tub transfer board
  • toilet tissue aid
  • positioning wedge
• Refer to sections 9.0 Self-care, and 11.0 Mobility of the Medical supplies and equipment guide and benefit lists for more information

Update to the guide to vision care benefits

• NIHB has updated the guide to vision care benefits to clarify eligibility criteria for protective and light blocking eyewear for clients who have low vision, are legally blind or have only one functioning eye
• To be eligible for coverage, clients must have a valid prescription from a licensed vision care professional
• For more information, refer to sections 3.1 Eligible services and 3.6 Low vision aids, ocular prosthesis and medication of the guide to vision care benefits

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, submit client reimbursement requests and 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 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

Dexcom, FreeStyle Libre System & FreeStyle Libre 2 System

• As of April 25, 2023, the NIHB Program will expand coverage of the continuous glucose monitoring (CGM) systems Dexcom G6, FreeStyle Libre and FreeStyle Libre 2
• These devices will be covered as limited use benefits for clients managing diabetes with insulin
• Prior approval is required. Coverage criteria are noted in the Drug Benefit List
• NIHB Program continues to provide coverage of diabetes test strips. Clients managing diabetes with insulin can access up to 800 test strips per 100 days

New pharmacy benefit listings

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

• The following new listings are covered as open benefits without prior approval:
  • Arazlo (tazarotene) lotion for the treatment of acne
  • Bryhali (halobetasol propionate) lotion for the treatment of plaque psoriasis
  • Pdp-levetiracetam (levetiracetam) injection and oral solution to treat and prevent seizures
  • Semglee (insulin glargine) prefilled pen, long-acting insulin to treat type 1 and type 2 diabetes
  • Kirsty (insulin aspart) injection and prefilled pen, rapid-acting insulin to treat type 1 and 2 diabetes
• The following new listings are covered as limited use benefits with prior approval:
  • Rinvoq (upadacitinib) for the treatment of rheumatoid arthritis and psoriatic arthritis
  • Braftovi (encorafenib), combined with other medications, for treatment of metastatic melanoma
  • Inqovi (cedazuridine-decitabine) for the treatment of adult patients with myelodysplastic syndromes (MDS)
  • Waymade-Trientine (trientine hydrochloride) for the treatment of patients with Wilson's disease who are intolerant to penicillamine
  • Tysabri (natalizumab) injection for the treatment of relapsing-remitting multiple sclerosis (RRMS)
  • Tukysa (tucatinib), when combined with other treatments, for the treatment of certain breast cancers
  • Actemra (tocilizumab) subcutaneous (SC) injection for certain types of arthritis in children or adults
  • Dupixent (dupilumab) 200/mg/1.14mL pen injection for patients aged 12 years and older with moderate to severe atopic dermatitis
  • Tagrisso (osimertinib) for patients with non-small cell lung cancer (NSCLC)
  • Reblozyl (luspatercept) for the treatment of certain blood disorders that cause anemia

Changes to replacement guidelines for certain items

• The recommended replacement guideline for floor-to-ceiling poles is now 1 per 10 years (up from one 1 per lifetime)
  • Find more information in section 9.7.3 of the Self-care equipment and supplies benefit list
• The replacement guideline for canes and quad canes is one 1 per 5 years (up from 1 per lifetime)
  • Find more information in section 11.4.1 of the Mobility equipment and supplies benefits list

Eligibility for Mental Health Counselling

• Coverage for mental health counselling 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 more information on client and service eligibility, please see section 3.0 of the Guide to mental health counselling benefits

Changes to predetermination and frequency guidelines for some services

• NIHB removed the predetermination requirement for coverage of:
  • surgical tooth extractions
  • prefabricated posts
  • first placement of a standard complete denture
    • replacement is already covered without predetermination within frequency guidelines
• Standard root canal treatments, also covered without predetermination, are no longer subject to program frequency guidelines

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-based 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
• Services identified as exclusions under the NIHB Program will not be considered for appeal
• 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

Reminder – submitting claims

• 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 website
• If you have coverage under another health benefit plan, your claim must be submitted to that plan first. Your other plan will provide you with an Explanation of Benefits (EOB) which you will need to submit when seeking reimbursement from NIHB for the remaining eligible amounts
• For more information on how to submit your client reimbursement by mail, fax, or through your online web account, please visit the Express Scripts Canada website
• Claims for medical transportation benefits are not processed by Express Scripts Canada
  • For more information, please visit NIHB Client Reimbursement

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