Refusal To Fill Fee
A pharmacy provider in British Columbia, Saskatchewan, or Manitoba may decide not to fill or refill a prescription when a claim has been rejected through the Drug Utilization Review and it is deemed to be in the best interest of the client. In these cases, a fee equal to the providers usual and customary fee may be charged to the NIHB Program. The provider is advised to use the ‘UL’ intervention code on his claim.
Trial Rx Program
In British Columbia and Saskatchewan, the NIHB Program may cover the dispensing fee associated with the provision of a small initial quantity of a ‘trial drug’ (seven-day supply) that is included under the Trial Prescription Program. To be applicable for reimbursement, the client must not have used the drug in the past two years.
Opioid Dependence Treatment
Methadone
- The dispensing fee for methadone will be based upon the following formula (usual and customary dispensing fee*/7) + $5.39 per dose.
- * Up to the Program’s regional maximum.
Suboxone & Kadian
- Usual and customary dispensing fee* per dispense.
- Separate claim submissions are required for pharmacy-witnessed doses and carry doses. 1 claim is to be submitted per pharmacy-witnessed dose and 1 claim is to be submitted for all carry doses combined, for example, regardless of the number of carry doses being dispensed at a time.
- (A separate reimbursement for witnessing the ingestion of Suboxone or Kadian via pseudo DIN 91500002 will no longer be available.)
- * Up to the Program’s regional maximum.
NIHB Prescriber Policy
Pharmacists are authorized to prescribe Schedule I drugs that fall within pharmacist’s scope of practice in Saskatchewan. Pharmacists also may recommend and be remunerated for Schedule II, III and unscheduled (non-prescription) drugs and eligible health products (eg. spacer devices and diabetic supplies) which are on the NIHB Drug Benefits List and are within pharmacist’s scope of practice.
3.12 Prescriber Policy for Pharmacy Benefits
In order to be eligible for reimbursement, the following conditions must be satisfied by all prescribers:
- licensed by and in good standing with the respective governing body or province in which they practice
- the prescription has been written in accordance with federal and provincial legislation
- the prescription falls within the health professional’s scope of practice, as defined by the relevant provincial and territorial regulations
In addition, the NIHB Program accepts client-specific written recommendations for Schedule II, III and unscheduled (non-prescription) drugs and eligible health products that are not included on a health professional’s prescribing list, when the item(s) falls within the prescriber’s scope of practice. The NIHB Program requires providers to maintain documentation related to claims submitted as a result of a health professional’s recommendation.
At a minimum this must include the following information:
- date
- name, and address or date of birth of the client
- proper name, common name, or brand name of the prescribed drug, and the quantity thereof
- dosage
- amount recommended
- signature of the health professional
Although not explicitly required by NIHB policy, PAS is recommending to document the clinical indication to prevent audit claw back. Claims submitted according to this policy will be reimbursed for the drug cost and dispensing fee according to NIHB reimbursement policies. Claims submitted according to this policy will be reimbursed for the drug cost and dispensing fee according to NIHB reimbursement policies. All claims are subject to claims verification. The NIHB Program does not compensate pharmacists for client assessment services.
Schedule II, III and unscheduled (non-prescription) drugs and eligible health products that are included within the NIHB Drug Benefits List that would not be considered in a pharmacist’s scope of practice include but are not limited to items such as Ensure™, Boost™ and any drug without a clinical indication.
The NIHB Prescriber Policy does not allow pharmacists to recommend Medical Supplies and Equipment (MS&E) such as bandages, dressing, pressure garments, etc. The MS&E policy is a different policy with a different MS&E benefit list .
For more information
- All pharmacy benefit related bulletins and policy can be found here
- All MS&E benefit related bulletins and policy can be found here
- Patients of the NIHB program can create a secure web account at Express Scripts Canada NIHB website, where they can:
o view their benefit claims history and status of pending requests
o submit client reimbursement requests online
o submit appeal requests online
o receive NIHB communication directly by email
If you have any questions or require further clarification on any NIHB policy, please contact Katherine Windl, Saskatchewan Regional Pharmacist, Non-Insured Health Benefits Directorate with First Nations & Inuit Health Branch at katherine.windl@canada.ca or contact the PAS office at info@skpharmacists.ca .