7.12 First Nations Health Benefits (Plan W)

Coverage is provided for individuals.

An individual must:

• Have active BC Medical Services Plan (MSP) coverage, and
• Be a registered Indian under the Indian Act, or be a child under 24 months of age, who has at least one parent who is a registered Indian under the Indian Act, and
• Not be an individual eligible to receive comprehensive drug coverage through
  • a treaty and land claims agreement under the Constitution Act, 1982 (Canada) (unless that treaty and land claims agreement has been identified by the provincial Minister of Health as not resulting in ineligibility), or
  • a written contribution arrangement between a First Nations organization and a government or province of Canada under which the government provides funding and which has been identified by the provincial Minister of Health as resulting in ineligibility for enrolment

PharmaCare cannot authorize Plan W coverage; eligibility for the plan is confirmed by the FNHA.

Under Plan W, PharmaCare pays 100% of

• Eligible prescription drug costs up to the maximum cost recognized by PharmaCare
• Certain over-the-counter medications and devices
• Dispensing and pharmacy services fee costs up to the maximum fee recognized by PharmaCare
  Note: There is no dispensing fee for non-drug over-the-counter items
• Plan W benefits purchased within Canada but outside B.C. if a request for reimbursement is submitted with appropriate documentation

FNHA confirms eligibility, and Plan W coverage is automatically uploaded to PharmaNet. Coverage is in effect from the time the individual’s eligibility for Plan W is uploaded to PharmaNet.

Plan W coverage cannot be provided retroactively.

Plan W beneficiaries should not pay for an OTC product that is covered by Plan W.  If a Plan W beneficiary chooses a covered OTC drug, pharmacists are expected to fill out HLTH 4571 - Plan W OTC Recommendation form (PDF, 548KB) and enter the claim in PharmaNet. Pharmacists are encouraged to recommend covered OTC drugs.

For a product in the Plan W OTC formulary to be eligible for coverage:

• A prescriber (a physician, nurse practitioner, pharmacist, or midwife) must write a prescription for it
  OR
• A pharmacist recommends treatment with the product. They then must complete the HLTH 4571 - Plan W OTC Recommendation form (PDF, 548KB) (for every dispense) and retain a record of the purchase. Claims entered without a completed Plan W OTC Recommendation form are subject to audit and recovery by PharmaCare, unless the drug was recommended as part of a Minor Ailments and Contraception Service assessment (see next bullet)
  OR
• A pharmacist recommends the drug as part of a Minor Ailments and Contraception Service (MACS) assessment. The pharmacist then must document the recommended OTC product on the MACS Form only. They do not record it on a Plan W OTC Recommendation form
  AND
• The pharmacy must enter the drug in PharmaNet.

Note: Insulin products are excluded from this policy. Insulins can be dispensed and the claim entered on PharmaNet without a prescription or a Plan W OTC Recommendation form (refer to Section 5.14—Insulin).

>> List of First Nations Health Benefits (Plan W) OTC Drugs. 

>> HLTH 4571 - Plan W OTC Recommendation form (PDF, 548KB)

>> MACS Form (PDF, 705KB)

>> Quick Links for Pharmacy Providers Assisting FNHA Clients (PDF, 121KB)

Covered under Plan W

PharmaCare covers specific devices under Plan W at their retail price up to a maximum set by FNHA, with no dispensing fee. (See Section 5.9—Retail Pricing Policy).

Claims for devices covered by PharmaCare automatically adjudicate under Plan W.

Please see the list of First Nations Health Benefits (Plan W) Non-Drug OTC PINs.

Specific medical supplies and equipment (MS&E) for FNHA clients are covered through FNHA’s private insurer.

>> See the list of FNHA MS&E benefits.

PharmaCare covers certain supplies under Plan W at the retail price, with no dispensing fee.

>> See the list of First Nations Health Benefits (Plan W) Non-Drug OTC PINs.

For individuals newly diagnosed with diabetes, who are covered under the First Nations Health Benefits (Plan W), FNHA covers the first fill for blood glucose test strips (BGTS), providing the BGTS are a PharmaCare benefit. For issues concerning coverage of BGTS for Plan W clients, contact the First Nations Health Benefits team at 1-855-550-5454.

Out-of-province purchases of Plan W benefits may be reimbursed if the client submits an HLTH 5480 - Out-of-Province claim form (PDF, 92KB) to PharmaCare with the appropriate documentation.

Occasionally, the FNHA client eligibility may not have been uploaded to PharmaNet, and the PharmaNet transaction will not provide the expected adjudication results.

1. In this case, call the PharmaNet Help Desk.
   
   The Help Desk will attempt to confirm active Plan W coverage. If coverage is confirmed, the Help Desk enters the coverage in PharmaNet to allow for the prescription to be processed under Plan W.
    
2. Once you receive confirmation that short-term assistance is in place, process the prescription as usual.

1. Enter the claim in PharmaNet as you would any other prescription; and
2. Retain a copy of the prescription on file.

1. Complete the HLTH 4571 - Plan W OTC Recommendation form (PDF, 932KB).
2. Enter the claim with P1 (for College of Pharmacists of BC) in the PRACT ID REF field and your own College Registration Identification (Reg ID) in the Prescriber ID field; and
3. Retain a record of the purchase similar to that required for prescription items.

1. Document the recommended OTC on the MACS Form (PDF).
2. Enter the claim with P1 (for College of Pharmacists of BC) in the PRACT ID REF field and your own College Registration Identification (Reg ID) in the Prescriber ID field; and
3. Retain a record of the purchase similar to that required for prescription items.