• Your drug is denied, why?
Feb 15, 2017

All First Nation members (even those 65 years of age or older) who do not have private insurance are covered by Health Canada's Non-Insured Health Benefits (NIHB) Program for their drugs (excluding Cree, Inuit and Naskapi residing on their territory).

 

Health Canada's Drug Benefit List is available on their website. By using the "Control F" function, you can easily find the name of a drug on the list.

 

2016 NIHB Drug Benefit List:

http://www.healthycanadians.gc.ca/publications/health-system-systeme-sante/nihb-drug-list-2016-liste-medicaments-ssna/alt/pub-eng.pdf

 

There are several categories of drugs.

 

If you cannot find the drug you are looking for on the list, it is probably because it falls into one of the categories that requires prior authorization from Ottawa's Drug Exception Centre (DEC). It is therefore the pharmacist's responsibility to contact the DEC for billing authorization.

 

If this procedure is not followed, it can result in delays or costs related to obtaining the drug.

 

Here's how it works:

 

Drug category

Examples

Must the pharmacist contact the DEC for billing authorization?

1-Covered without restriction

Acetaminophen, Ibuprofen, Gravol, Penicillin, Heparin, Prozac

No

2-Limite use

Codeine, Fentanyl, Lyrica, Pantoloc, Concerta

Yes

3-Exception

Biphentin, Synvisc, Strattera, Oxyneo

Yes

4-Non-benefit

Daxas, Sativex, Victoza, Ultram

Yes

Health Canada requires that the client file an appeal application to review whether the drug reimbursement will be approved

5-Exclusion

Imovane, cough syrup with codeine, anti-obesity agent, vaccines linked to travel

Yes

To ensure that the drug is an exclusion

 

When your client shows up at the pharmacy counter, the pharmacist must enter the Drug Identification Number (DIN) into their computer system.

 

When the drug is in the first category, no problem! The prescription is provided on the spot at no cost to the customer.

 

On the other hand, if the drug falls into one of the other categories, the pharmacy's computer system will indicate that the drug is not covered by the Program. This is an automated response by default. This does not mean that the drug cannot be covered.

 

Most pharmacists immediately contact the DEC which triggers the authorization process but some pharmacists neglect this important step and may be tempted to bill your client.

 

It is therefore very important to ensure that the pharmacist contacts the DEC when they inform you that the requested drug is not covered or when they ask your client to pay for their prescription.

 

DEC: 1-800-281-5021 (for pharmacists only).

 

Health Canada's Claims Processing Centre: 1-877-483-1575 (for clients).

 

Unfortunately, it is possible that the drug may not be covered even if your pharmacist contacts the DEC but it is important to ensure that this step has been carried out.

 

If the drug is not covered, the client has two options:

1- Ask the pharmacist to contact the prescribing physician and change the prescription to an alternative treatment that is covered by the NIHB Program.

 

2- Initiate an appeal process.

 

If you need support or information about the appeal process, please contact the FNQLHSSC's Health Care Liaison Agent.

 

Note that when Health Canada agrees to cover a drug, it provides 100% coverage. If a residual amount still needs to be paid (e.g. $3.50, $0.30, $1.29), it is probably a problem related to the synchronization of the drug cost management computer systems. Ask the pharmacist to contact Express Script Canada at 1-888-511-4666 to correct the situation.

 

 

 

Isabelle Verret

Health Care Liaison Agent

iverret@cssspqnl.com

418-842-1540, ext. 2704