Non-Insured Health Benefits program updates

NIHB Drug benefit list

• The NIHB Drug benefit list provides up-to-date information on medications and health products that are eligible for coverage under NIHB's pharmacy benefit
• Clients, pharmacists and prescribers can search for specific medications and products by using the online Drug benefit list, located on the Express Scripts Canada NIHB website
  • for best results, search medications by 'chemical name' (such as ibuprofen, not Advil), then 'view details' to see the listing status and criteria for each product
• The complete Drug benefit list is also available as a PDF file, now located on the Express Scripts Canada NIHB website
  • click 'Download Drug Benefit List' to access the PDF
• The NIHB Drug benefit list is updated regularly as new medications and products are added for coverage

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:

• Bijuva (estradiol-progesterone) 1/100mg capsule for the treatment of moderate to severe 'hot flashes' due to menopause
• Nypozi (filgrastim) for the treatment of certain cancers, patients with Severe Chronic Neutropenia (SCN) or patients with HIV infection
• Mezera (mesalazine) tablets for treatment of mild to moderate ulcerative colitis
• Ketorolac tablets for short-term treatment of moderate to severe pain following surgery

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

• Saphnelo (anifrolumab) for treatment of lupus in adults
• Ultomiris (ravulizumab) for treatment of paroxysmal nocturnal hemoglobinuria and atypical hemolytic uremic syndrome, which are rare blood disorders
• Qulipta (atogepant) for prevention of chronic migraine in adults
• Zeposia (ozanimod) for treatment of moderate to severe ulcerative colitis
• Kerendia (finerenone), used along with other treatments to reduce the risk of serious complications in adults with chronic kidney disease and type 2 diabetes

Discontinuation of sole prescriber restrictions under the Client Safety Program

• As of July 2, 2024, NIHB no longer restricts clients to a sole prescriber for opioids, benzodiazepines, stimulants, gabapentin, pregabalin, and/or nabilone, under the Client Safety Program
• This measure was initially introduced by NIHB in 2007 to reduce risks that can occur if prescriptions for these medications are obtained from multiple doctors. It applied to clients being treated for opioid use disorder or based on patterns of prescription drug use
• However if clients have difficulty finding a sole prescriber, this presents a barrier to access when these medications are required
• Provinces and territories now have enhanced prescription monitoring programs or electronic medical records, so doctors and pharmacists can see prescribing patterns that show a risk to client safety
• NIHB continues to have other client safety measures in place to promote safe and effective use of prescription medications
• Dose limits still apply for NIHB coverage of these above medications, and a maximum of 30 days' supply can be dispensed at one time

Emergency supply policy for clients receiving end-of-life care or cancer treatment

• The End‐of‐Life Formulary provides special coverage for clients diagnosed with a terminal illness who are near the end of life. The Adjunct Cancer Formulary addresses the needs of clients undergoing cancer treatments
• For clients with access to these special formularies, NIHB's emergency supply policy now allows pharmacists to dispense up to 14 days supply of these medications, while waiting for prior approval forms to be returned
• Clients at the end of life or undergoing cancer treatments are also exempt from NIHB opioid dose limits, when requested by pharmacy providers

Changes to predetermination, frequency guidelines and coverage for some dental services

NIHB has made the following changes to dental benefit coverage. Consult the Dental benefits guide for more information:

• The first dental visit/orientation for children 3 years of age and under no longer requires predetermination
• Coverage for pulpotomy/pulpectomy on primary (baby) teeth now includes primary incisors for clients under the age of 5
• Prefabricated metal crowns for permanent teeth no longer require predetermination
• Emergency exams are no longer subject to a frequency guideline, and no longer count against the maximum number of eligible annual exams
• Coverage for topical application of an antimicrobial or remineralization agent, including silver diamine fluoride, to lesions on the teeth has increased to 2 treatments in 12 months for clients 17 years of age and over
• Focal plane tomograms, a type of x-ray, are now eligible for coverage

Modifications to footwear

• Foot care professionals can modify your footwear to help address a range of foot conditions and symptoms
• NIHB now covers one modification per footwear item per year (left, right or both), when the service has been prescribed by a doctor, nurse or podiatrist
• All necessary alterations performed at a single time are considered as one modification
• For more information, see section 4.0 Footwear of the MS&E Guide and Benefits Lists

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:

• Imvexxy (estradiol) vaginal insert for the treatment of painful intercourse after menopause

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

• Jakavi (ruxolitinib phosphate) for the treatment of complications after stem cell or bone marrow transplants in clients aged 12 years and older
• Beovu (brolucizumab) for the treatment of some macular degeneration and diabetic eye disease
• Vyepti (eptinezumab) for the treatment of migraines
• Lorbrena (lorlatinib) for the treatment of certain lung cancers in adults
• Xpovio (selinexor) combined with other medications, for the treatment of myeloma, a cancer that affects white blood cells
• Verzenio (abemaciclib) and Lynparza (olaparib) for the treatment of breast cancers
• Lenvima (lenvatinib mesylate) for the treatment of endometrial or kidney cancer
• Qinlock (ripretinib) for the treatment of certain gastrointestinal tumors
• Cibinqo (abrocitinib) and Rinvoq (upadacitinib) for the treatment of moderate to severe eczema in clients aged 12 years and older
• Tremfya (guselkumab) for the treatment of plaque psoriasis and psoriatic arthritis
• Tezspire (tezepelumab) injections for the treatment of severe asthma in clients aged 12 years and older
• Evenity (romosozumab) for the treatment of osteoporosis after menopause
• Rybelsus (semaglutide) for the treatment of type 2 diabetes in adults, used along with diet and exercise, metformin or other medications to lower blood sugar
• Dexcom G7 system for patients managing diabetes with insulin

Changes to oxygen benefits

• NIHB now provides coverage for M9 oxygen cylinders and moustache or pendant style oxygen conserving devices as limited use benefits. Prior approval is required
• For more information, please refer to section 5.0 Oxygen of the Medical supplies and equipment guide and benefit lists

Oxygen holders as open benefit

• NIHB now covers oxygen cylinder holders for walkers and wheelchairs. Prior approval is not required within NIHB unit price
• For more information, please refer to section 11.0 Mobility of the Medical supplies and equipment benefit lists

Licensed practical nurses/registered practical nurses as recommenders of standard and wheeled commodes

• NIHB now accepts recommendations from licensed practical nurses and registered practical nurses for coverage of standard and wheeled commodes
• For more information, please refer to section 9.2 of the Self-care equipment and supplies benefits list

Registered nurses as recommenders of offloading diabetic walking boots

• NIHB now recognizes registered nurses as eligible recommenders of offloading diabetic walking boots and its custom-made foot bed liners
• For more information, please refer to section 3.4.8 of the Limb and body orthotics equipment and supplies benefit list

Updated frequency guidelines

• NIHB now aligns mental health counselling benefit coverage with the calendar year, from January 1 to December 31
• There is no change to the amount of benefit coverage available. NIHB clients are eligible for coverage of up to 22 hours of counselling every 12 months. Benefit coverage will refresh on January 1 each year
• In order to transition to calendar year frequency, going forward, prior approvals will be set with an end date of December 31. Providers have been advised of this change and can submit new prior approval requests for 2025 as needed
• For more information on coverage and frequency guidelines, please see section 3.3 of the Guide to mental health counselling benefits

Reminder - coordination of benefits

• If clients are eligible for a vision care service that is covered through another health benefit plan or program (such as a provincial program or employer sponsored benefit plan), the other plan should be accessed before submitting the claim to NIHB
• Clients that have coverage through another plan are encouraged to let their vision care provider know before they receive the service, so the provider can update their client's profile and submit the claim to the other plan first
• Once the other plan has paid, any remaining eligible balance can be submitted to NIHB for reimbursement. The other plan will provide an Explanation of Benefits (EOB) which must be submitted to NIHB along with the NIHB client reimbursement form
• Any amount of NIHB coverage that a client has not used will remain available until the end of the frequency period
• If there are any changes to your coverage through another benefit plan, let your vision care provider know so they can update your information
• You can update NIHB about changes to other coverage by contacting the NIHB Call Centre at Express Scripts Canada (ESC) at 1-888-441-4777 or your NIHB regional office

Removal of predetermination requirement for the replacement of selected partial dentures

• A predetermination is no longer required for the replacement of selected partial dentures within frequency guidelines for:
  • Partial acrylic dentures, covered once in any 5 year period
  • Partial cast dentures, covered once in any 8 year period
• NIHB encourages you to speak with your dental provider to confirm your eligibility prior to receiving the service
• More information can be found in the Dental Benefits Guide

Information on the Canadian Dental Care Plan

• The Canadian Dental Care Plan and the NIHB program both cover a broad and similar range of dental services
• There is no change to how First Nations and Inuit access dental coverage through NIHB. Eligible clients should continue to access the dental coverage available to them through Indigenous Services Canada's NIHB program
• If NIHB clients wish to apply to the Canadian Dental Care Plan, they should claim through the NIHB program first
• Indigenous Services Canada is working closely with Health Canada to ensure ongoing alignment of dental coverage between the two plans, and that NIHB clients can continue to receive all their federally funded dental care coverage through NIHB

Expanded coverage for low vision items and services

• NIHB has expanded coverage for low vision equipment and services under the Medical supplies and equipment benefit
• NIHB listed 31 new items in the following low vision sub-benefit categories:
  • low vision aids (such as, handheld digital magnifiers)
  • assistive technology (such as, text to speech software, brailler)
  • orientation and mobility aids (such as, GPS technology)
  • independent living aids (such as, digital audio player)
• For complete information, please refer to section 10.0 Low vision equipment and supplies of the Medical supplies and equipment guide and benefits list
• Clients with low vision or severely restricted vision may also be eligible for coverage of low vision functional assessments and training programs
• For more information on functional assessments and training programs, including prior approval requirements, please refer to section 10.6 Services of the Low vision equipment and supplies benefits list
• NIHB now recognizes 4 new prescribers for low vision items:
  • Certified Vision Rehabilitation Therapist (CVRT)
  • Certified Orientation and Mobility Specialist (COMS)
  • Assistive Technology Specialist (ATS)
  • Low Vision Specialist/Certified Low Vision Therapist (LVS/CLVT)
• Find more information on prescribers and providers in section 10.1.2 Prescriber and provider requirements of the Low vision equipment and supplies benefits list
• Clients that are eligible for coverage of these benefits through another health benefit plan or program (such as a provincial program or employer sponsored benefit plan) should access the other plan first

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 limited use benefits with prior approval:

• Scemblix (asciminib HCI) for the treatment of adult patients with a specific type of leukemia
• Dojolvi (triheptanoin) for the treatment of patients with long-chain fatty acid oxidation disorder (LC-FAOD), a disease where the body has trouble breaking down fat for energy
• Vraylar (cariprazine hydrochloride) for the treatment of patients with schizophrenia
• Retevmo (selpercatinib) for the treatment of adult patients with thyroid cancer
• Vabysmo (faricimab) for the treatment of patients with diabetic macular edema or wet age-related macular degeneration
• Givlaari (givosiran) for the treatment of patients with acute hepatic porphyria, a rare genetic condition affecting the liver and nervous system
• Firdapse (amifampridine phosphate) for the treatment of patients with Lambert-Eaton Myasthenic Syndrome, a rare autoimmune disease
• Byooviz (ranibizumab) for the treatment of patients with certain eye disorders

Reminder: non-prescription products recommended by pharmacists

• NIHB accepts pharmacist recommendations for over-the-counter medications that are eligible for coverage
• This means you don't need a prescription from a doctor for coverage of non-prescription items on the NIHB drug benefit list when the product is recommended by a pharmacist
• Here are just a few examples of products that can be recommended by pharmacists for NIHB coverage:
  • smoking cessation products
  • prenatal multivitamin and folic acid
  • lice treatment
• Check the NIHB drug benefit list to find eligible pharmacy benefits covered by NIHB, as well as any criteria for coverage
• More information on this policy can be found in section 3.12 of the Guide to Pharmacy Benefits

Reminder: changes to other coverage

• Please let NIHB know as soon as possible if there are changes to your other health benefit coverage (for example, through an employer sponsored plan)
• Clients whose other coverage has changed can update their information for one or more benefit areas by contacting the NIHB Call Centre at Express Scripts Canada (ESC) at 1-888-441-4777
• When contacting ESC, clients should specify which benefit areas are affected and the effective date of the change to their coverage status

Reminder: direct deposit

• Clients can receive reimbursement of processed NIHB claims by direct deposit. Direct deposit is a convenient, fast and secure way to receive payments
• Express Scripts Canada processes NIHB client reimbursement claims for pharmacy, dental, medical supplies and equipment, vision care and mental health counselling benefits. To receive payments by direct deposit:
  • visit the Express Scripts Canada NIHB client reimbursement web page
  • fill out the Direct Deposit and Communication Preference Form for NIHB Clients, located at the bottom of the page, and return it to Express Scripts Canada by mail, fax or through your client web account
• Client reimbursement requests for NIHB medical transportation benefits are processed by Indigenous Services Canada regional offices, or by communities administering medical transportation benefits through contribution agreements. Contact your NIHB regional office, or community medical transportation coordinator for more information. To enroll for direct deposit:
  • fill out the ISC Direct Deposit Request form and return it to the mailing address indicated on the form
• Please note that reimbursement payments to someone other than the client (for example, a community or the parent of a child under 16 years) can only be made by cheque

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:

• DermOtic oil (fluocinolone acetonide) 0.01% ear drops for the treatment of chronic eczema

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

• Toctino and Hanzema (alitretinoin) for the treatment of severe and chronic hand eczema
• Diacomit (stiripentol) for the treatment of epilepsy in infants
• Increlex (mecasermin) for the treatment of growth failure in children and adolescents from 2 to 18 years of age
• Scemblix (asciminib) 20 mg and 40 mg tablets are limited use benefits for treatment of adult patients with Philadelphia chromosome-positive chronic myeloid leukemia (Ph+ CML)

Expanded coverage for Guardian insulin pump and CGM systems

• The NIHB Program has expanded coverage for the following diabetes management devices:
  • Guardian Connect continuous glucose monitoring (CGM) system
  • Guardian Link 3 Transmitter Kit for 670G insulin pump system and integrated CGM
  • Guardian Link 3 Transmitter Kit for 770G insulin pump system and integrated CGM
  • Guardian Link 3 Transmitter Kit for 780G insulin pump system and integrated CGM
• These devices are now covered as limited use benefits for clients 19 years of age or younger managing diabetes with insulin, and all clients with type 1 diabetes
• Prior approval is required. Coverage criteria are noted in the Drug Benefit List
• NIHB continues to provide coverage of diabetes test strips. Clients managing diabetes with insulin can access up to 800 test strips per 100 days

New listings for hospital beds and accessories

• NIHB now lists hospital beds and related accessories as limited use benefits. Prior approval is required
• Hospital beds can be claimed with or without rails, based on the client's requirements. Examples of benefits covered by NIHB include:
  • electric hospital bed
  • bariatric bed mattress
  • pressure relief mattress
• Refer to section 9.0 Self-care of the medical supplies and equipment benefit list for more information.

New coverage for oxygen supplies

• NIHB will now provide coverage for the rental of a low flow oxygen meter/adaptor as a limited use benefit. Prior approval is required
• NIHB will now cover new oxygen connectors and adapters at a recommended replacement guideline of 6 per year. Prior approval is not required
• More information can be found in section 5.0 Oxygen equipment and supplies benefits list

Increased reimbursement rate for custom-made foot orthotics

• NIHB has increased the reimbursement rate for custom-made foot orthotics to $525 per pair
• More information can be found in section 4.0 Footwear equipment and supplies benefit list

Registered Respiratory Therapists (RRT) as eligible NIHB recommenders

• NIHB now accepts recommendations from Registered Respiratory Therapists (RRT) for coverage of certain equipment and supplies such as:
  • secretion clearance items
  • tracheostomy supplies
  • renewal of communication benefits
  • oxygen and respiratory equipment and supplies once the therapy is prescribed by an eligible prescriber (for example, doctor or nurse practitioner)
• For more information on eligible items, prescription and recommendation requirements, please consult the Medical Supplies and Equipment Benefit List

Missed or cancelled appointments

• If you need to cancel a mental health counselling appointment, virtual or in person, please notify your provider as soon as possible
• The NIHB program does not reimburse providers for missed or cancelled appointments
• Talk to your provider to find out their policies for missed or cancelled appointments, such as whether they charge clients a fee for their time if a client misses an appointment or advance notice of a cancellation is not provided. Note that NIHB will not reimburse clients for these fees
• If NIHB medical transportation arrangements have been made, you must also notify your medical transportation coordinator or NIHB regional office to cancel travel arrangements

Client reimbursement requests for medical transportation

• Client reimbursement requests for medical transportation benefits are processed by Indigenous Services Canada regional offices, or by communities administering medical transportation benefits through contribution agreements
• Medical transportation reimbursement requests are not processed by Express Scripts Canada. If you send these to Express Scripts Canada, they will be returned to you
• To ensure the trip falls within NIHB policy and to confirm coverage, please contact your NIHB regional office or other organization managing medical transportation benefits
• To submit a client reimbursement request for medical transportation benefits:
  • visit the Indigenous Services Canada (ISC) Forms by category webpage
  • select the "Client Reimbursement Request - Medical Transportation" form
  • print and complete the form and send it in to your NIHB regional office

Submitting client reimbursement requests for multiple benefits

• Express Scripts Canada processes NIHB client reimbursement requests for pharmacy, dental, vision care, medical supplies and equipment, and mental health counselling benefits
• When submitting client reimbursement requests, you must use a separate form for each benefit type (such as pharmacy, dental or vision care)
• You can include multiple items or services on the same form, as long as they are the same type of benefit
  • For example, you can include several dental services on the same form, but must use a new form for vision care services
  • For submission by mail or fax, the client reimbursement form is available for download on the Client reimbursement page of the Express Scripts Canada NIHB website. You can also call Express Scripts Canada to have it mailed to you
• When submitting a request through your web account, begin by selecting the benefit type (such as, dental), filling out the online form, uploading applicable documents, then clicking submit. If needed, you can return to the claim submission screen and select another benefit type (such as, vision care)
• Find complete instructions and the list of documents required for each benefit type on the Client reimbursement page of the Express Scripts Canada NIHB website
• Whether you submit client reimbursement requests through mail, fax or your web account, using separate forms for each benefit type will ensure that your claim is sent to the right department for processing, without delay