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DRUG Benefits Content Drug Benefits 62 The Drug Exception Centre 63 The Drug Benefit List 64 Classification of the drugs on the NIHB list 66 Prescription Drug Insurance in Quebec 68 What is the prescription trajectory for a First Nations patient? 74 Why is the pharmacist asking your client to pay for their drugs? 75 Reason 1 - The drug is an exception 77 Reason 2 - The drug is excluded from the program 78 Reason 3 - The drug quantity that is normally granted for a renewal has been exceeded or the renewal frequency limit is not being respected. 79 Reason 4 - Overbilling by the pharmacist 79 A - The pharmacist’s profit margin is too large; 81 B - Due to the poor synchronisation of the electronic systems. 82 Reason 5 - Your client has just received their status. 85 Reason 6 - Coordination of the benefits. 87 Generic Drugs vs. Original Drugs DRUG BENEFITS DRUG Health Canada’s drug benefits program covers a limited range of drugs. This federal program has its own drug benefit list which is different from the one used by the Régie d’assurance ma- ladie du Québec (RAMQ), which makes it one of the more complex programs for the Quebec region. The various preauthorisation processes associated with this program have the effect of complicating access and comprehension. Depending on the drug category, the pharmacist is subjected to Health Canada’s preauthorisation process in order to be able to provide the prescribed drug to their patient free-of-charge. See the table explaining the drug categories on pages 64 and 65 of this section. A list of drugs that are covered by the NIHB program does exist. However, it is not an exhaus- tive list. The list does not include all of the drugs that could be covered by the program (excep- tions, non-benefits, etc.), which has the effect of complicating the work of the physicians who wish to prescribe a treatment to their patient. CONTENT - Drug Benefits 61 THE DRUG EXCEPTION CENTRE (sometimes referred to as the “Department of Indian Affairs” by some professional/providers). The Drug Exception Centre is located in Ottawa and hires dozens of people who are responsi- ble for evaluating, analysing and authorising all of the prescription drugs requiring prior authorisation, additional medical justifications, etc. Only the pharmacists can contact this centre. There is no customer service intended for the clients or the workers in the First Nations communities. Each time the pharmacist’s electronic system indicates that a prescription is not covered by the NIHB program, the pharmacist must initiate an exception request by directly calling the Drug Ex- ception Centre in Ottawa. The pharmacist then receives a number associated with the authorisation request for the drug in question. The decision regarding coverage for the patient’s treatment will be confirmed by fax once the prescribing physician has justified the treatment to the Drug Exception Centre. The Centre also has discretionary powers related to the reimbursement of medication in exceptional situations. See the trajectory of a prescription on page 67 of this section. Contrarily to the Drug Exception Centre, the role of Health Canada’s Claims Processing Centre in Montreal is minimal with respect to drug benefits. It is possible for the Montreal office to provide some information regarding the steps that have been taken in a client’s file. Moreover, in order to obtain information regarding a request, Health Canada’s Montreal office is the only organisation that can be contacted by the workers and clients from the First Nations communities. Health Canada’s Claims Processing Centre: 1-877-483-1575. GPS • GUIDE TO PROCEDURES FOR ACCESSING HEALTH SERVICES 62 THE DRUG BENEFIT LIST As previously mentioned, the NIHB program includes its own drug benefit list, which is different from the one offered by the provincial plan of the RAMQ for non-Aboriginal people. The RAMQ’s drug benefit list is analysed and updated by the Conseil du médicament du Qué- bec. Considering that the majority of the pharmaceutical companies are located in Quebec and that their lobbying efforts are quite significant, new pharmaceuticals have a tendency to appear on the RAMQ’s list more quickly. Meanwhile, the NIHB drug benefit list is a national list. It applies to all First Nations across Ca- nada and does not take into consideration the evolution of the drug benefit lists of the provincial plans such as the RAMQ. The NIHB Drugs and Therapeutics Advisory Committee (DTAC) is the national committee per- forming analyses with the power of recommendation for any additions or modifications to the NIHB drug benefit list. However, Health Canada is the only decision-making authority that can determine what will be added to the list. The physicians who practice in Quebec are accustomed to accessing the RAMQ’s drug benefit list, but very few of them are familiar with using the NIHB’s list. This is explained by the fact that, due to the low percentage of First Nations among the Quebec population, the RAMQ’s list is used more in their daily practice. Before prescribing a drug to a First Nations patient, the physician should first of all ensure that the drug they are recommending is included in the NIHB drug benefit list. However, to that end, it is important for the patients to identify themselves as being First Nations members. It is also important to be aware that the NIHB drug benefit list is available online but it is not systematically distributed among the physicians by Health Canada. NIHB DRUG BENEFIT LIST If you would like to access the drug benefit list, it is very easy to find using Goo- gle by entering: NIHB drug benefit list. CONTENT - Drug Benefits 63 CLASSIFICATION OF THE DRUGS ON THE NIHB LIST The NIHB program’s drug benefit list is available online. However, it does not include many drugs that could be covered by the program (exception, exclusion, etc.), which has the effect of complicating the work of the physicians who wish to prescribe treatment to their patients. It is important to be aware that certain drugs require patients to try other treatments first before they can be approved by Health Canada. This is often one of the reasons justifying payment de- nial by Health Canada. All of the drugs covered by virtue of the NIHB program require a prescription. Drugs are classified as follows: Category Description Medical Appeal justification from processes the physician Over-the- These are available on the shelves of the Only if the quantity Very rarely counter drugs pharmacies, but require a prescription in or frequency limit order to be covered by the NIHB program. is exceeded. Drugs that are These are drugs that are included in the Only if the quantity Very rarely covered with NIHB drug benefit list and for which no or frequency limit restriction prior authorisation is required. is exceeded. Exception These are not included in the NIHB drug Always through a Sometimes drugs benefit list and must be approved on a form sent to the case by case basis supported by medical prescribing physi- justification. cian by the Drug The eligibility criteria for exception drugs Exception Centre. are not available to the health professio- nals or patients and they are not available online. Only the Drug Exception Centre knows what they are. Limited use Limited use drugs are perceived as being Always through a Sometimes drugs useful under certain circumstances, or are form sent to the subjected to restrictions regarding quantity prescribing physi- or administration frequency. These drugs cian by the Drug are only covered if their use meets specific Exception Centre. eligibility criteria. The eligibility criteria for certain limited use drugs are available in the drug benefit list of the NIHB program and online. However, only the Drug Exception Centre knows them all. GPS • GUIDE TO PROCEDURES FOR ACCESSING HEALTH SERVICES 64 (cont'd) Category Description Medical Appeal justification from processes the physician Drugs that are These are not included in the drug benefit Always Mandatory not included list of the NIHB program. in the list Coverage for this type of drug is systemati- (non-benefits) cally denied but can sometimes be considered under exceptional circumstances within the context of an appeal request. The physician is then required to provide medical justification. Drugs that are not included in the list as well as their eligibility criteria are not available for the health professional or the patients and are not available online. Only the Drug Exception Centre knows what they are. Drugs that are Certain drugs are considered to be Never Never excluded from excluded from the NIHB program. the NIHB pro- The appeal process and emergency supply gram policy do not apply to drugs that are excluded from the NIHB program. Certain additional drugs that are not included in the NIHB drug benefit list can be covered for certain specific clienteles such as those suffering from renal failure or palliative care patients. These clienteles can be identified through the usual prior authorisation process. See the form for palliative care in the section. See the descriptions for each of the classes of drugs in the NIHB information booklet on pages 21 and 22. CONTENT - Drug Benefits 65 PRESCRIPTION DRUG INSURANCE IN QUEBEC According to An Act respecting Prescription Drug Insurance in Quebec, those who are Aboriginal according to the Indian Act (status Indians) do not have access to Quebec’s public drug insurance plan and therefore cannot benefit from drugs covered by the RAMQ. First Nations members must access drugs through Health Canada’s (federal government) NIHB program.

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