Non-Insured Health Benefits (NIHB) Program: Changes in Other Coverage and Extension of Approvals

IMPORTANT INFORMATION FOR PHARMACY PROVIDERS:


Changes in other coverage

If an NIHB eligible client no longer has other health benefits coverage, for example if they have lost employer sponsored coverage, and CPhA code C6 (Patient has other coverage) is returned by the pharmacy software, there are two options to process the claim:

• From 8:00 a.m. to 6:00 p.m. Monday to Friday (all time zones), please contact the Drug Exception Centre (DEC) at 1-800-580-0950 to adjust the client’s file. Such a change takes effect immediately. • After hours, on the weekend or holidays, the provider can process the claim by using the “DB” intervention code to override the error message.

Extension of Approvals

Due to the COVID-19 pandemic, NIHB is proactively extending approvals of certain limited use medications where existing approvals were due to expire from April through June 2020. The medications included at this time are: biologics, oral chemotherapy, OFEV and Esbriet.

This is in addition to the previous announcement that NIHB has temporarily removed prior approval requirements on many limited use medications so they can be submitted as open benefits without prior approval for initial and renewal requests.

Extended approvals will come into effect once the client’s current prior approval expires. If you have a client on one of these medications and their prior approval is no longer valid, please remove the prior approval number (ex. E6848561) from your claim and try to bill directly.

If you are still unable to bill for one of these medications, please call the Drug Exception Centre (1-800-580-0950) for assistance.

Please note that these approvals only apply to clients that have a valid prior approval through NIHB.

Chiefs of Ontario

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