Plan W covers eligible prescription drugs, certain over-the-counter (OTC) medications, and some medical supplies/devices for First Nations Health Authority (FNHA) clients.
Coverage is provided for individuals.
An individual must:
PharmaCare cannot authorize Plan W coverage; eligibility for the plan is confirmed by the FNHA.
Under Plan W, PharmaCare pays 100% of
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 lists OTC medications to help address the health disparities faced by First Nations Health Authority clients, as a result of colonialism, and to support First Nations Health Authority clients in meeting their health and wellness goals.
Plan W OTC drug benefits are eligible for 100% coverage when the claims are entered in PharmaNet, subsequent to:
Pharmacists can dispense a Plan W OTC item recommended by another pharmacist. They enter the recommending pharmacist's College Registration Identification (Reg ID) in the prescriber ID field.
For every OTC item dispensed under Plan W, the dispensing pharmacy can claim the maximum dispensing fee and mark-up covered by PharmaCare.
The dispensing pharmacy must retain a record of the OTC Recommendation form, the MACS Form or prescription, and consult with the client following requirements outlined under the Health Professions Act, Bylaws Schedule F, Part 1 section 11(2), (3) and (4), and section 12, and the Pharmacy Operations and Drug Scheduling Act (PODSA) Bylaw section 23(1)(a), (2), (3).
Supporting FNHA clients with accessing OTC drug benefits is a component of culturally safe pharmacy care. Pharmacists are expected to explore Plan W OTC medications and provide a covered product when in the best interest of the client. Should a pharmacist decide to not recommend and/or provide an OTC drug benefit requested by an FNHA client, they should discuss therapeutic options and advise the client to seek further care as appropriate.
Frequency of dispensing
PharmaCare will not reimburse pharmacies for dispensing fees when a Plan W OTC is prescribed for daily and/or frequent dispensing.
Audit
Plan W OTC claims are subject to audit by the Ministry of Health and the First Nations Health Authority, and any amount associated with a disallowed claim will be recovered.
Insulin products
Insulin products are excluded from this policy. Insulins can be dispensed and entered in PharmaNet without a prescription or a Plan W OTC Recommendation form. Refer to Section 5.14—Insulin.
PharmaCare covers specific devices under Plan W at their retail price up to a maximum set by FNHA, with no dispensing fee. Refer to Section 5.9—Retail Pricing Policy.
Claims for these devices automatically adjudicate under Plan W.
Please refer to First Nations Health Benefits (Plan W) Non-Drug OTC PINs.
PharmaCare covers certain supplies under Plan W at the retail price, with no dispensing fee.
For Plan W clients newly diagnosed with diabetes, FNHA covers the first fill of blood glucose test strips (BGTS), providing the BGTS are a PharmaCare benefit. For questions about BGTS coverage for Plan W clients, contact the First Nations Health Benefits team at 1-855-550-5454.
Specific medical supplies and equipment (MS&E) for FNHA clients are covered through FNHA’s private insurer.
Out-of-province purchases of Plan W benefits may be reimbursed if the client submits an HLTH 5480 - Out-of-Province claim (PDF, 656KB) 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.
For questions regarding eligibility for Plan W, clients and pharmacists can contact FNHA at 1-855-550-5454 or by email at HealthBenefits@fnha.ca.
For questions regarding PharmaCare Plan W coverage and claims, pharmacies can contact the PharmaCare Help Desk, and clients should contact HIBC.