Are Pharmacy Benefits/Drugs covered by the Non-Insured Health Benefits (NIHB) Program?
Yes. The NIHB Program covers prescription drugs and some over-the-counter products listed on the NIHB Drug Benefit List (DBL).
If you already have drug coverage through your work (private insurance) or through a provincial/territorial health insurance plan, your pharmacist must submit the claim for payment to your other plan first. If you do not have another health plan, then your pharmacist will submit the drug claim to the NIHB Program.
How do I access NIHB pharmacy benefits?
First, you must be eligible under Health Canada's Non-Insured Health Benefits Program. If you are, you must then obtain a prescription from a physician or other licensed prescriber and that prescription must be filled at a pharmacy.
Pharmacies that are registered with the NIHB Program can bill the Program directly at no expense to you.
Who can prescribe drugs under the NIHB Program?
To be recognized by the NIHB Program, the prescriber must be a physician or other licensed health practitioner with authorization to prescribe medication within the scope of practice in their province or territory and within the mandate of the Program.
Who can provide NIHB pharmacy benefits?
You may take your prescription to any licensed pharmacy to be filled. However, only those pharmacies that have registered with the NIHB Program can bill the Program directly rather than requiring that you pay upfront.
The NIHB Program strongly encourages pharmacies to bill the NIHB Program directly. However, if you choose a pharmacy that is not registered with NIHB, you must pay the bill directly and then submit your receipts to NIHB for possible reimbursement.
If your pharmacy chooses not to bill the NIHB Program directly, you can contact the Health Canada regional office which may assist you in finding a pharmacy in your area which bills the NIHB Program directly.
The pharmacist should tell you, as the client, if you will have to pay for services upfront.
Can I continue to use my current pharmacy if they do not bill the NIHB Program directly?
Yes, that is your choice. However, it is recommended that you contact the Health Canada regional office before filling prescriptions or purchasing prescribed items, to ensure that these are eligible for coverage under the NIHB Program.
In cases where the pharmacy does not directly bill the NIHB Program, remember that you must pay for your prescription first, and then submit all necessary documentation to the NIHB Program to be considered for reimbursement.
Remember that your pharmacy may charge more than the amount that is covered by NIHB, which means that you would not be reimbursed the full amount you paid.
Your request for reimbursement can be submitted to NIHB up to one year from the date on which the services were received.
What is a prescription drug?
A prescription drug is a medication that can be provided only with a prescription from a health care professional who is licensed to prescribe by the province or territory (most commonly a doctor, dentist, nurse practitioner) before it can be filled by a pharmacist.
What is an 'Over-The-Counter' (OTC) drug?
Over-the-counter drugs can be sold at a pharmacy without a prescription, for example, an antihistamine or acetaminophen. Over-the-counter drugs listed on the NIHB Drug Benefit List require a prescription in order to be covered by the NIHB Program.
What is an 'Open Benefit Drug'?
Open benefit drugs are listed on the NIHB Drug Benefit List and are covered without the need to meet established coverage criteria.
What are 'Limited Use Benefits'?
Limited Use Benefits are drugs listed on the NIHB Drug Benefit List and have specific criteria that must be met by the client's medical condition if these are to be approved for coverage by the NIHB Program.
When I filled my prescription I received a generic drug. Why?
The NIHB Program covers the costs of the 'lowest cost alternative drug'. This means that the NIHB Program will reimburse only the best price for a same drug, which is commonly known as a generic drug and is the same as the brand-name product.
If the client cannot take the generic drug because of an adverse drug reaction to that generic drug, the NIHB Program will cover a brand name drug at a higher cost. However documentation will be required from the prescriber explaining why the generic drug is not an option.
Is prior approval required before billing the NIHB Program for a prescription?
The NIHB Program maintains a comprehensive Drug Benefit List and most prescribed drugs are included on that list, so the pharmacist can dispense them immediately.
However, the pharmacist must obtain prior approval from the national NIHB Drug Exception Centre in Ottawa when the:
What is not covered by the NIHB Program? (Exclusions)
Exclusions include drug therapies for particular conditions which fall outside the NIHB mandate and are not covered as benefits under the NIHB Program. Some examples include, but are not limited to:
To find out more about what is excluded, please consult the NIHB Drug Benefit List.
Does NIHB have special benefits available for chronic renal failure clients?
Chronic renal failure clients may be eligible to receive a list of supplemental benefits/drugs that are required on a long-term basis and which are not included as benefits for all NIHB clients.
Does NIHB have special benefits available for palliative (end of life) clients?
Clients who have a terminal illness and are near the end of their life may be eligible to receive a list of benefits/drugs not included as benefits for all NIHB clients.
Is there an appeal process when a benefit has been denied?
A client, parent, legal guardian or representative may initiate an appeal when an eligible benefit has been denied by the NIHB Program.
For a case to be appealed, a signed note or letter from the client, parent or legal guardian, accompanied by supporting information from the service provider or prescriber (e.g. a doctor) must be submitted to the NIHB Program. There are three levels of appeal available.
Where can I get more information about the NIHB Pharmacy Benefit?
How do I contact the Health Canada regional office in my area?
A complete list of Health Canada regional offices is available.
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 2012/2013.
The Pharmacy and Medical Supplies and Equipment Benefits - Policy Framework (2010) is intended to provide stakeholders, providers and clients with a broad overview of the parameters of the NIHB Program policies as they relate specifically to the pharmacy and medical supplies and equipment (MS&E) benefit area.
Visit the Reports and Publications section to access a wide variety of Non-Insured Health Benefits documents.