Message from Non-Insured Health Benefits about Benefit Exception Process

Submitted by Robert Cluett, NTC NIHB, December 20, 2012

DENIAL - Prescription Drugs Client “Benefit Exception Process”

Prescription Drugs NOT normally approved can follow the {Exception Process} outlined below:

Step One……….Client gets prescription from doctor/specialist

Step Two……….Client takes prescription to their Pharmacy

Step Three……..Pharmacy {advocates} calls Drug Exception Centre – Ottawa

Step Four….Drug Exception Centre faxes a form to clients’ doctor for completion

Step Five….Family Doctor completes form and returns to Drug Exception Centre

Step Six……Drug Exception Centre informs Pharmacy of their Decision

Step Seven…..Pharmacy informs client of results

When this result is still “not approved” the client has the option of appealing the decision, guided by the appeal process. 

It is strongly encouraged client contact their home community [CHR-Community Health Representative for further information/assistance or the Nuu-chah-nulth Tribal Council {NIHB- Non-Insured Health Benefits] Program Department regarding the written appeal process – at the toll free number 1-888-407-4888 or locally in Port Alberni at 250-724-5757. 

For urgent assistance on these matters contact either of the above numbers and ensure you inform your doctor immediately – when the “not approved decision” happens!

Pending client wishes to write the letter on their own accord, client must initiate and sign this letter - The letter must contain the following information:  {Assistance is highly encouraged}

  1. The condition for which the benefit is being requested
  2. The diagnosis and prognosis (including other alternatives have been tried)
  3. Relevant diagnostic test results
  4. Justification for the proposed treatment and any additional supporting documentation

The Appeal will be reviewed by a medical professional and the decision will be made based on your specific needs, accumulated research, the availability of alternatives and the Non-Insured Health Benefits (NIHB) policy.

Address:  The Director of the NIHB Drug Exception Centre – Medical Services Branch Health Canada – Address Locator 6103A – 3rd Floor – 1547 Merivale Road, Nepean, Ontario – K1A OL3

DENIAL - Prescription Drugs Client “Benefit Exception Process”

Prescription Drugs NOT normally approved can follow the {Exception Process} outlined below:

Step One……….Client gets prescription from doctor/specialist

Step Two……….Client takes prescription to their Pharmacy

Step Three……..Pharmacy {advocates} calls Drug Exception Centre – Ottawa

Step Four….Drug Exception Centre faxes a form to clients’ doctor for completion

Step Five….Family Doctor completes form and returns to Drug Exception Centre

Step Six……Drug Exception Centre informs Pharmacy of their Decision

Step Seven…..Pharmacy informs client of results

When this result is still “not approved” the client has the option of appealing the decision, guided by the appeal process. 

It is strongly encouraged client contact their home community [CHR-Community Health Representative for further information/assistance or the Nuu-chah-nulth Tribal Council {NIHB- Non-Insured Health Benefits] Program Department regarding the written appeal process – at the toll free number 1-888-407-4888 or locally in Port Alberni at 250-724-5757. 

For urgent assistance on these matters contact either of the above numbers and ensure you inform your doctor immediately – when the “not approved decision” happens!

Pending client wishes to write the letter on their own accord, client must initiate and sign this letter - The letter must contain the following information:  {Assistance is highly encouraged}

  1. The condition for which the benefit is being requested
  2. The diagnosis and prognosis (including other alternatives have been tried)
  3. Relevant diagnostic test results
  4. Justification for the proposed treatment and any additional supporting documentation

The Appeal will be reviewed by a medical professional and the decision will be made based on your specific needs, accumulated research, the availability of alternatives and the Non-Insured Health Benefits (NIHB) policy.

Address:  The Director of the NIHB Drug Exception Centre – Medical Services Branch Health Canada – Address Locator 6103A – 3rd Floor – 1547 Merivale Road, Nepean, Ontario – K1A OL3

Date: 

Thursday, December 20, 2012