10.0 Low vision equipment and supplies benefits list
Effective date: June 28, 2023
The following Medical Supplies and Equipment (MS&E) list contain low vision items and services provided as eligible benefits by the Non-Insured Health Benefits (NIHB) program for eligible First Nations and Inuit, along with information on coverage policies, benefit codes, requirements for prior approval and applicable recommended replacement guidelines.
Table of contents
10.1 General information
10.1.1 Benefit policies
General information common to all medical supplies and equipment (MS&E) can be found in the general policies.
10.1.2 Prescriber and provider requirements
Prescriptions or recommendations for coverage must be initiated by the health professionals identified as prescribers or recommenders of the item under the NIHB program. Items that are prescribed by prescribers/recommenders not recognized by NIHB will lead to denials or reversal of claims.
The following is a list of NIHB recognized prescriber/recommender abbreviations found in this segment of the benefits list. Please refer to the prescriber section of the item tables below to identify the eligible prescriber/recommender of a specific item:
- LVS — Low Vision Specialist
- MD — Physician
- NP — Nurse Practitioner
- O.D. — Doctor of optometry (optometrist)
- OMT — Certified Ophthalmic Technician/Medical Technologist working under Stanton Territorial Health Authority in NWT and Nunavut
- OT — Occupational Therapist
- RN — Registered Nurse
The following is a list of NIHB recognized provider abbreviations found in this segment of the benefits list. Please refer to the provider section of the item tables below to identify the eligible provider of a specific item:
- GEN — Enrolled general medical supplies and equipment or pharmacy provider
10.1.3 Prior approval requirements
General prior approval requirements can be found in the general policies.
To initiate the prior approval process, the Low Vision Prior Approval Form, found on the Express Scripts Canada NIHB provider and client website, must be completed in full and submitted to your NIHB regional office along with the following supporting documentation:
- the prescription or recommendation or referral form signed by an NIHB recognized prescriber for the requested benefit
- additional relevant information the provider, prescriber may have to support the request
- an explanation of benefits from any third-party coverage available to the client (for example: provincial plan, workers' compensation board, private insurance, education plan, etc.)
10.1.4 Exclusions
General exclusions may be found under general policies.
10.1.5 Warranties
Providers must honour the manufacturer's warranty.
10.1.6 Repairs
Repairs that are not covered under the warranty are eligible for coverage when supported by proper documentation.
The following rules apply:
- prior approval is required
- request must include detailed cost breakdown of parts, labour time and rates
- repairs must have a minimum warranty of 90 days
A description of all repairs with dates, detailed cost breakdown of parts, labour time and rates must be kept on file for each client.
Note: The NIHB program will not cover the labour cost for repairs that are covered under the warranty.
10.1.7 Replacement requirements
Recommended replacement guidelines indicate the quantity and frequency at which a benefit item will be eligible for coverage. Recommended replacement guidelines are based on a client's customary medical needs and the typical device's lifespan.
Replacement is subject to the same process as the original purchase.
All requests for replacement require a new prescription.
For more general information please see section 1.12 Recommended replacement guidelines.
10.1.7.1 Early replacement requirements
Coverage requests for any early replacement require prior approval, a new prescription as well as documentation supporting the need for early replacement. The client must meet program and equipment specific eligibility criteria.
Early replacement of items may be considered when one of the following has occurred:
- there is a substantial change in a client's medical condition (for example, substantial change in vision status, etc.) and the item no longer meets the client's needs
- the item is no longer functioning properly, has deteriorated during typical use and is no longer under warranty (where the cost of repair exceeds the cost of a new item)
The program will not cover the replacement of lost items, stolen items, or items that are damaged due to misuse or negligence.
10.1.8 Services included in the price
The following services must be included in the price of the item to be considered for coverage:
- product and parts ordering and delivery from manufacturer to provider (including delivery costs, exchange rate)
- dispensing of the benefit, which includes any required adjustments or fittings
10.1.9 Terminology
Item code
The item code is an 8-digit code that identifies the benefit being requested and is submitted to Express Scripts Canada for billing purposes.
Prior approval
A program coverage confirmation is issued by a NIHB regional office to a provider to ensure that the client is eligible for specific medical supplies and equipment benefits. The approval is issued primarily for items identified as requiring prior approval before being billed to the program.
Recommended replacement guidelines
The recommended replacement guidelines set a maximum number of each item a client may receive over a given period of time (frequency). Coverage of additional items may be considered on a case-by-case basis. For requests exceeding the recommended replacement guidelines, a prior approval is required.
Unit price
Unit price information may be found on the price files, located on the Express Scripts Canada NIHB provider and client website.
10.2 Low vision aids
10.2.1 Magnifier
| Item number | Item name | Prescriber | Provider | Prior approval required | Recommended replacement guidelines | Additional details |
|---|---|---|---|---|---|---|
| 99400868 | Magnifier | LVS, O.D., OMT, OT, RN, NP, MD | GEN | Yes | ||
| 99400869 | Magnifier, illuminated head | LVS, O.D., OMT, OT, RN, NP, MD | GEN | Yes | ||
| 99400870 | Magnifier, illuminated handle | LVS, O.D., OMT, OT, RN, NP, MD | GEN | Yes | ||
| 99400871 | Microscope | LVS, O.D., OMT, RN, NP, MD | GEN | Yes | ||
| 99400872 | Telescope or monocular | LVS, O.D., OMT, RN, NP, MD | GEN | Yes |
10.2.2 Cane
| Item number | Item name | Prescriber | Provider | Prior approval required | Recommended replacement guidelines | Additional details |
|---|---|---|---|---|---|---|
| 99400874 | White cane | LVS, O.D., OMT, RN, NP, MD | GEN | Yes | ||
| 99400875 | White cane tip | LVS, O.D., OMT, RN, NP, MD | GEN | Yes | 3 per year |
10.2.3 Other
| Item number | Item name | Prescriber | Provider | Prior approval required | Recommended replacement guidelines | Additional details |
|---|---|---|---|---|---|---|
| 99400873 | Coloured filters | LVS, O.D., OMT, RN, NP, MD | GEN | Yes | ||
| 99400876 | Face cradle, rental | LVS, O.D., OMT, RN, NP, MD | GEN | Yes | covered for post-op recovery for vitrectomy surgery |
10.3 Servicing
10.3.1 Delivery
| Item number | Item name | Prescriber | Provider | Prior approval required | Recommended replacement guidelines | Additional details |
|---|---|---|---|---|---|---|
| 99401267 | Delivery, low vision | GEN | Yes | Delivery of equipment to client |