Coordination of Benefits Information for Non-Insured Health Benefits (NIHB) Clients - August 2012

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Many people have health coverage under more than one benefit plan - for example, you may have health coverage through your employer and through the NIHB Program. If this is the case, you can use both plans when claiming pharmacy expenses.

Coordinating your benefits

Each time you submit a claim, please confirm the details of all your health insurance plans with the pharmacist. This will enable them to submit claims to the right plan in the right order. For NIHB eligible benefits, the NIHB Program will cover any remaining amount not covered by your other plan(s).

Coordinating benefits with other plans that have electronic claims processing

If your other health insurance plan has electronic claims processing or bills on-line, the pharmacist will automatically directly bill the maximum allowable amount to your plan and then bill the remaining amount for the NIHB eligible benefit to the NIHB Program.

Coordinating benefits with other plans that have manual claim processing

Manual plans require clients to pay for their prescriptions at the time of purchase and submit their receipts for reimbursement. If your other coverage is with an insurance plan that has a manual claims process the procedure to get your prescriptions filled will be different than a plan that has on-line billing.

To coordinate your manual plan and NIHB:

• You will be required to pay for your prescription upfront then complete and mail a manual claim form to your health insurance plan to receive reimbursement for your prescription.
• To claim any remaining amount for an NIHB eligible benefit not covered by your other insurance, you must submit the following items to your respective Health Canada regional office:
  • The statement of benefits from your manual claim plan;
  • An official prescription receipt; and
  • A completed and signed NIHB Client Reimbursement Form (PDF version 91 K).

Coordinating benefits with other plans that have deferred claim processing

Deferred payment plans require clients to pay for the prescription at the pharmacy and the pharmacy submits the prescription claim on-line to the plan on clients' behalf. Clients will receive reimbursement directly from the deferred payment plan in the mail. This is different than a plan that has on-line billing. To coordinate your deferred plan and NIHB:

• You will be required to pay for your prescription upfront.
• To claim any remaining amount for an NIHB eligible benefit not covered by your other coverage, you must submit the following items to your respective Health Canada regional office:
  • The statement of benefits from your deferred claim plan;
  • An official prescription receipt; and
  • A completed and signed NIHB Client Reimbursement Form (PDF version 91 K).

Change in your coverage status

To avoid delays when having your prescriptions filled, whenever there are changes to your insurance coverage, please:

• Inform your pharmacist so they can update the information on your profile in their pharmacy software.
• If you have new coverage, contact your other health insurance plan to confirm the name of the plan and contact details to give to your pharmacist during your next visit.
• If additional coverage you had has ended, because you changed jobs or no longer qualify under another plan, you will be required to bring, send or fax to your Health Canada regional office, one of two things: either a copy of the message sent to the pharmacy from your insurance indicating coverage is terminated; or you must obtain information, in writing, from your insurance company confirming that the other coverage has been terminated. This information is required so that the necessary changes can be made in the NIHB computer system.
• If your other plan refuses to coordinate with NIHB the pharmacist may fill your prescription under NIHB. Please bring, send or fax one of two things to your Health Canada regional office: either a copy of the message sent to the pharmacy from your health insurance plan indicating refusal; or you must obtain information in writing from your insurance company confirming that the other coverage refuses to coordinate with NIHB. This information is required to make the necessary changes in the NIHB computer system.

For more information on the NIHB Program, please visit the NIHB website at http://www.hc-sc.gc.ca/nihb. Go to the Benefits Information section for the NIHB Client Reimbursement Form.