Drug Benefits

The Non-Insured Health Benefits (NIHB) Program covers prescription and over-the-counter medications that are not covered by other private or provincial/territorial health insurance plans.

The objective of the drug benefit program is to provide eligible clients with access to pharmacy services that will contribute to optimal health outcomes in a fair, equitable and cost-effective manner and will:

1. Contribute to improving the overall health status of First Nations and Inuit clients recognizing their unique health needs and the context of health service delivery; and
   
   
2. Fund drug benefits and services based on professional judgement, consistent with the current best practices of health services delivery and evidence-based standards of care.

What is covered?

• Prescription drugs listed on the Non-Insured Health Benefits Drug Benefit List and
• Approved over-the-counter medication.

The NIHB Program covers the 'lowest cost alternative drug' which is commonly known as a generic drug. The policy of the NIHB Program is to reimburse only the best price alternative or equivalent product in a group of interchangeable drug products.

The NIHB Program will pay for prescription drugs with a higher cost if the recipient cannot take the generic drug as a result of an adverse reaction to the generic drug.

How do eligible recipients access drug benefits?

• Recipients must obtain a prescription from a physician or other licensed prescriber;
• The prescription should be taken to a pharmacy to be filled. Or, it can be taken to a nursing station, which may arrange to have the prescription filled on behalf of the recipient at a local pharmacy;
• Recipients may contact the Regional Office should they require more information.

Is there an appeal process when a benefit is not covered?

Eligible recipients can submit an appeal when coverage for a benefit is declined. Please refer to the Appeal Procedures section.

Who can prescribe under the NIHB Program?

A doctor or other health professional licensed to prescribe by a province or territory.

Who can provide drug benefits?

Drug benefits must be provided by a registered pharmacist.

Is prior approval required before billing the NIHB Program for a prescription?

The NIHB Program maintains a comprehensive Drug Benefit List. In most cases, the drugs that are prescribed are on the list and the pharmacist can dispense them immediately.

However, the pharmacist must obtain approval when the:

• Drug is not on the NIHB Drug Benefit List;
• Physician has written 'no substitution' on the prescription;
• Drug is listed as a 'limited use drug' requiring prior approval; or
• Drug is a 'maximum allowable' drug.

See the Provider Guide for Pharmacy Benefits section for details on the benefit policies, procedures and resources for health providers.

Resources

Distribution of NIHB Pharmacy Expenditures ($ Millions) 2007/08

Source: Framework Integrated Resource Management System (FIRMS) adapted by Program Analysis Division

For more information on NIHB drug benefits provided, see the Non-Insured Health Benefits Program Annual Report 2007/2008.

Visit the Reports and Publications section to access a wide variety of Non-Insured Health Benefits documents.