FNHA has been purchasing services from Health Canada to process client claims for dental, drugs and medical supplies since transfer in 2013. FNHA entered into an agreement with the Ministry of Health and transitioned our drug benefits to BC PharmaCare Plan W on October 1, 2017. This is a first-of-its-kind provincial First Nations drug benefit plan.
Plan W offers 100% coverage of the eligible costs of drugs, dispensing fees, and pharmacy services, including many over-the-counter medications. FNHA clients are now covered by PharmaCare and subject to the same PharmaCare policies and processes as other BC residents. Plan W is the first payer and primary pharmacy drug plan for eligible FNHA clients.
A small number of items continue to be covered by Health Canada's Non-Insured Health Benefits (NIHB) program to ensure continuity of therapies. Additionally, medical supplies and equipment (MS&E) continue to be covered by NIHB until they can also be transitioned. A Third Party Provider will be introduced in approximately late 2018 to replace NIHB and provide coverage for MS&E items and those few drugs that are not covered by PharmaCare.
FNHA and PharmaCare, in partnership with pharmacy software vendors have ensured that claims will automatically adjudicate with PharmaCare as the first payer for eligible FNHA clients. The change should be transparent to users of the system. These updates allow FNHA client claims to be processed through PharmaNet and adjudicated as first payer against PharmaCare without a "host processing error." The local pharmacy software will then submit claims that have been rejected and/or not fully paid by PharmaCare to an extended healthcare plan (if client has one) and then to the FNHA-NIHB Residual plan.
Should a system adjudication issue occur, please contact your software vendor.
It is important to note that the FNHA and BC PharmaCare have worked together to ensure the smoothest possible transition to the new PharmaCare plan. For instance:
• The vast majority of FNHA clients have been enrolled in the new PharmaCare plan automatically. • FNHA clients who currently have Special Authorization for a drug through the NIHB have been given transitional Special Authority coverage under PharmaCare.• All FNHA clients currently taking a drug that is partially covered under the Reference Drug Program have been given indefinite, full PharmaCare coverage of their current medication.
• The vast majority of FNHA clients have been enrolled in the new PharmaCare plan automatically.
• FNHA clients who currently have Special Authorization for a drug through the NIHB have been given transitional Special Authority coverage under PharmaCare.
• All FNHA clients currently taking a drug that is partially covered under the Reference Drug Program have been given indefinite, full PharmaCare coverage of their current medication.
These are just a few examples of the strategies that have been put in place to reduce disruptions to patient coverage and to reduce administration for health care providers.
BC PharmaCare is a provincial program and it cannot directly pay for eligible prescriptions filled outside the province. This is a significant change for some FNHA clients. We ask that all health care providers remind FNHA clients to plan ahead before they travel by obtaining the maximum days' supply of their medication before they leave the province.
FNHA clients who have paid for an eligible prescription filled out-of-province should be encouraged to request reimbursement from PharmaCare by using this Out-Of-Province Client Reimbursement Form with the official pharmacy receipts attached.
No, not all First Nations individuals in BC are eligible for PharmaCare Plan W. There are still a small number of NIHB clients in BC, such as those insured under another benefit plan provided by a First Nations Organization pursuant to self-government agreements (e.g. Nisga'a).
First Nations individuals residing out of province who are visiting BC are covered by NIHB and not PharmaCare.
Your Point of Sale System should adjudicate FNHA clients appropriately based on their Personal Health Number. First Nations in BC who are eligible for FNHA Health Benefits should also be eligible for the FNHA PharmaCare plan. Questions related to enrollment with FNHA can be directed to FNHA Health Benefits at 1-855-550-5454.
No, the NIHB Provider agreement remains in place to handle NIHB claims.
The issue is most likely with your pharmacy's point-of-sale (POS) software or the client profile configuration in the software. Please ensure your pharmacy software submits claims for FNHA clients as a regular PharmaCare claim, not a federally insured client. Additionally, claims should be submitted without any intervention codes or zeroing out the dollars. If you have any additional questions with your point-of-sale software, please contact your software vendor.
FNHA is actively ensuring that the Special Authorities are grandparented into PharmaCare are loaded into the system. If FNHA clients meet the Transitional Coverage criteria but do not have a Special Authority in place, pharmacists can submit this Transitional Coverage Request form. (This form is available for transitional issues on a short-term basis, including this situation for special authorities). Pharmacists requiring additional support are also encouraged to call FNHA Health Benefits at 1-855-550-5454.
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