The Non-Insured Health Benefits Prescription Monitoring Program
(NIHB-PMP)

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Fact Sheet for Health Professionals
For more information call:
1 877-559-9986
The Non-Insured Health Benefits Prescription Monitoring Program (NIHB-PMP)

April 2012

What is the Non-Insured Health Benefits Program?

The Non-Insured Health Benefits (NIHB) Program is Health Canada's national health benefit program that provides coverage for medically necessary drugs, dental care, vision care, medical supplies and equipment, short-term crisis intervention mental health counselling and medical transportation for eligible registered First Nations and recognized Inuit.

The NIHB Program aims to enhance the safe use of prescription medications and ensure that benefit criteria are met before claims are paid.

Why has NIHB implemented a Prescription Monitoring Program?

The NIHB Program has implemented a Prescription Monitoring Program (PMP) to address concerns over potential abuse and misuse of prescription medications such as benzodiazepines, opioids, stimulants and gabapentin.

In the past, a client could be seeking prescriptions from several different prescribers simultaneously and filling them at multiple pharmacies. Therefore, no single prescriber or pharmacist could assess the appropriateness of the sum total of the drugs prescribed and dispensed. This led to concerns over client health and safety and also to verification of benefit criteria regarding benzodiazepines, opioids, stimulants and gabapentin.

Briefly, how does the NIHB-PMP work?

If a client's pattern of drug utilization covered by NIHB exceeds a safe established threshold, that client is asked to choose a single prescriber to write all prescriptions for benzodiazepines, opioids, stimulants and/or gabapentin. Once a physician has agreed to be the client's only prescriber, NIHB will cover the cost of those prescriptions, which can be dispensed at any pharmacy. 

How will the NIHB-PMP resolve health and safety concerns?

When prescriptions for a client's benzodiazepines, opioids, stimulants and/or gabapentin are limited to a single prescriber, that prescriber will be aware of ALL benzodiazepine, opioid, stimulant and/or gabapentin prescriptions covered by the NIHB Program.

Note: All other medications on the NIHB drug benefit list will be covered as usual even if they are prescribed by other physicians.

Who makes the decisions regarding the NIHB-PMP?

The NIHB-PMP is managed by Health Canada's health professionals. These health professionals oversee the clinical aspects and implementation of the NIHB PMP in order to promote the safe use of benzodiazepines, opioids, stimulants and gabapentin. They provide recommendations on specific clients to be placed in the NIHB-PMP.

How does a client get placed in the NIHB-PMP?

Clients who have been prescribed inappropriate quantities of benzodiazepines, opioids, stimulants and/or gabapentin are identified by a drug utilisation review. A NIHB health professional then reviews the anonymized drug profiles and if an individual's NIHB drug profile exceeds established thresholds, the client's drug profile is submitted to other health professionals for their review and recommendation.

What will happen at the pharmacy?

When the client attempts to fill a prescription, the pharmacy will receive a rejection message and be asked to call the NIHB Drug Exception Centre (DEC) at a toll-free number. After speaking to a DEC representative, the pharmacy will receive by fax two copies of this Fact Sheet, and the following three documents that should be given to the client:

1. Letter to Client
   This letter will inform the client that in order for NIHB to continue paying for benzodiazepines, opioids, stimulants and/or gabapentin, they will have to choose only one physician to prescribe these medications.
2. Physician-Acceptance Form
   This form must be completed by the physician of the client's choice who agrees to be their sole prescriber of benzodiazepines, opioids, stimulants and gabapentin.
3. Client-Physician Contract
   This is a tool to assist the physician and client in describing their agreement.

Will the pharmacy be paid for this work and interaction?

Yes. The pharmacy will be paid a dispensing fee (DF) when the client attempts to have a prescription filled for the first time after being placed in the NIHB-PMP. The pharmacist will be issued a Prior Approval for the client by the DEC for a specific pseudo-DIN (91500001) with which they will be able to submit a claim for a single DF.
The DF will cover the cost of:

• calling DEC and speaking to the NIHB representative,
• accepting the faxed documents from NIHB, AND
• giving the three documents plus one copy of the Fact Sheet to the client. The other copy of the Fact Sheet is for the pharmacist.

If the client has difficulty understanding the documents, this pharmacist will be well positioned to explain the document contents and to direct the client to call the toll-free telephone number for additional information.

What happens after the client has been given the three documents? 

Until the client has chosen a single physician and NIHB has received a signed Physician-Acceptance Form, the NIHB Program will reject payment for claims submitted for benzodiazepines, opioids, stimulants and gabapentin by pharmacies.  However, a pharmacist is authorized to dispense one 7-day supply of the medication until the client has chosen a physician.

What does this mean for physicians?

When a client asks a physician to be their sole prescriber of benzodiazepines, opioids, stimulants and/or gabapentin, they should bring the previously mentioned three documents and Fact Sheet to the physician's office. A physician is under no obligation to accept this request. However, if the physician accepts, they need to:

• Sign the physician acceptance form and fax it back to NIHB. This will enable NIHB to resume coverage of prescriptions for benzodiazepines, opioids, stimulants and/or gabapentin.
• Consider completing the Client-Physician Contract as a tool to clarify their agreement. If this optional contract is completed, it should also be faxed back to NIHB.